Objectives Critically review presentations on 1. Local therapy 2. Adjuvant chemotherapy for isolated local regional recurrence 3. The optimal duration of endocrine therapy 4. Advances in HER2 directed therapies
From: Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis: A Randomized Clinical Trial JAMA. 2011;305(6):569-575. doi:10.1001/jama.2011.90 ACOSOG Z11 randomized a similar population to observation or ALND after a positive SLN. Primary endpoint was OS. Need for any local therapy after positive sentinel lymph node biopsy? Figure Legend: ALND indicates axillary lymph node dissection; SLND, sentinel lymph node dissection. Date of download: 9/25/2013 Copyright 2012 American Medical Association. All rights reserved.
How does this impact clinical care? In women with < T2, clinically N0 breast cancer, no further axillary surgery is needed after breast conserving treatment. In similar patients who undergo mastectomy, axillary XRT is an option, but is it necessary?
How does this impact clinical care? A course of adjuvant chemotherapy after an isolated local regional recurrence improves DFS and OS. The benefits appear less convincing for hormone receptor positive disease.
Objectives Critically review presentations on 1. Local therapy 2. Adjuvant chemotherapy for isolated local regional recurrence 3. The optimal duration of endocrine therapy 4. Advances in HER2 directed therapies
ATLAS*/aTTOM Very large, pragmatic studies (1996-2005) No restrictions on age, hormone receptor status, nodal status or other treatments No protocol-defined visits or evaluations except for yearly MD questionnaire Protocol amended in 2000 when 5 years of tamoxifen was superior to 2 years *Published online Lancet 12/5/12
Table 1, ER+ tumors Tamoxifen x 5 years n=3418 Age, years % Tamoxifen x 10 years N=3428 <45 18 19 45-54 32 32 55-69 40 40 >70 10 9 Nodal status % N0 54 53 1-3 nodes 26 27 >4 nodes 16 16 Tumor size % T1 47 48 T2 39 38 T3 7 7 Menopausal status % Premenopausal 9 10 Postmenopausal 89 89
Figure 3 Recurrence (A) and breast cancer mortality (B) by treatment allocation for 6846 women with ER-positive disease Bars show SE. Recurrence rates are percentage per year (events/patient-years of follow-up). Death rates (overall rate???rate... Christina Davies, Hongchao Pan, Jon Godwin, Richard Gray, Rodrigo Arriagada, Vinod Raina, Mirta Abraham, V... Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial The Lancet null 2012 null http://dx.doi.org/10.1016/s0140-6736(12)61963-1
Figure 2 Treatment compliance (A) and proportion of patients in follow-up (B) by year since randomisation for 6846 women with ERpositive disease (54% node-negative) *>99% tamoxifen. Christina Davies, Hongchao Pan, Jon Godwin, Richard Gray, Rodrigo Arriagada, Vinod Raina, Mirta Abraham, V... Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial The Lancet null 2012 null http://dx.doi.org/10.1016/s0140-6736(12)61963-1
How does this impact clinical care? For patients who are appropriate candidates for tamoxifen therapy, 10 years of tamoxifen is recommended. The results of these trials do not provide data on any strategies that have incorporated aromatase inhibitors.
How does this impact clinical care? Strategies with improved DFS compared to 5 years of tamoxifen: 1. 10 years of tamoxifen 2. 5 years of an aromatase inhibitor (AI) 3. 2-3 years of tamoxifen then 2-3 years of AI (total 5 years) 4. 5 years of an AI after 5 years of tamoxifen
Objectives Critically review presentations on 1. Local therapy 2. Adjuvant chemotherapy for isolated local regional recurrence 3. The optimal duration of endocrine therapy 4. Advances in HER2 directed therapies
*pcr = no invasive disease in breast
How does this impact clinical care? One year of adjuvant trastuzumab remains the standard of care. The mtor pathway may be an important target in trastuzumab resistant MBC, but the role of mtor inhibitors is not well defined, with approval of TDM-1 and pertuzumab. The addition of pertuzumab to trastuzumab in the neoadjuvant setting with docetaxel has just been approved.
Thank you. Questions?