Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015

Annals of Oncology, Aug 2015

The 14th St Gallen International Breast Cancer Conference (2015) reviewed substantial new evidence on locoregional and systemic therapies for early breast cancer. Further experience has supported the adequacy of tumor margins defined as ‘no ink on invasive tumor or DCIS’ and the safety of omitting axillary dissection in specific cohorts. Radiotherapy trials support irradiation of regional nodes in node-positive disease. Considering subdivisions within luminal disease, the Panel was more concerned with indications for the use of specific therapies, rather than surrogate identification of intrinsic subtypes as measured by multiparameter molecular tests. For the treatment of HER2-positive disease in patients with node-negative cancers up to 1 cm, the Panel endorsed a simplified regimen comprising paclitaxel and trastuzumab without anthracycline as adjuvant therapy. For premenopausal patients with endocrine responsive disease, the Panel endorsed the role of ovarian function suppression with either tamoxifen or exemestane for patients at higher risk. The Panel noted the value of an LHRH agonist given during chemotherapy for premenopausal women with ER-negative disease in protecting against premature ovarian failure and preserving fertility. The Panel noted increasing evidence for the prognostic value of commonly used multiparameter molecular markers, some of which also carried prognostic information for late relapse. The Panel noted that the results of such tests, where available, were frequently used to assist decisions about the inclusion of cytotoxic chemotherapy in the treatment of patients with luminal disease, but noted that threshold values had not been established for this purpose for any of these tests. Multiparameter molecular assays are expensive and therefore unavailable in much of the world. The majority of new breast cancer cases and breast cancer deaths now occur in less developed regions of the world. In these areas, less expensive pathology tests may provide valuable information. The Panel recommendations on treatment are not intended to apply to all patients, but rather to establish norms appropriate for the majority. Again, economic considerations may require that less expensive and only marginally less effective therapies may be necessary in less resourced areas. Panel recommendations do not imply unanimous agreement among Panel members. Indeed, very few of the 200 questions received 100% agreement from the Panel. In the text below, wording is intended to convey the strength of Panel support for each recommendation, while details of Panel voting on each question are available in supplementary Appendix S2, available at Annals of Oncology online.

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Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015

Tailoring therapies-improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015 A. S. Coates 2 8 E. P. Winer 1 8 A. Goldhirsch 0 8 R. D. Gelber 6 8 M. Gnant 5 8 M. Piccart-Gebhart 4 8 B. Thürlimann 3 8 H.-J. Senn 7 8 Panel Members 8 0 International Breast Cancer Study Group, Program of Breast Health (Senology), European Institute of Oncology , Milan , Italy 1 Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School , Boston , USA 2 International Breast Cancer Study Group, University of Sydney , Sydney , Australia 3 Breast Center , Kantonsspital St Gallen, St Gallen 4 Internal Medicine/Oncology, Institut Jules Bordet , Brussels , Belgium 5 Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria 6 International Breast Cancer Study Group Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School , Boston , USA 7 Tumor and Breast Center ZeTuP , St Gallen , Switzerland 8 Fabrice André, Research Director, Department of Medical Oncology, Institut Gustave Roussy , 114 rue Edouard Vaillant, 94805 Villejuif , France José Baselga, Memorial Sloan Kettering Cancer Center , 1275 York Avenue, New York, USA Jonas Bergh , Radiumhemmet & Karolinska Oncology, Karolinska Institutet and University Hospital , 171 76, Stockholm , Sweden Hervé Bonnefoi , Institut Bergonié Cancer Center, Université de Bordeaux , Bordeaux, France Harold Burstein , Department of Medical Oncology/Solid Tumor Oncology, Dana-Farber Cancer Institute , 450 Brookline Avenue, Boston, MA 02215, USA Fatima Cardoso , Director Breast Unit, Champalimaud Cancer Center, Avenida Brasilia , 1400-038 Lisbon, Portugal Monica Castiglione-Gertsch , International Breast Cancer Study Group , Ef The 14th St Gallen International Breast Cancer Conference (2015) reviewed substantial new evidence on locoregional and systemic therapies for early breast cancer. Further experience has supported the adequacy of tumor margins defined as 'no ink on invasive tumor or DCIS' and the safety of omitting axillary dissection in specific cohorts. Radiotherapy trials support irradiation of regional nodes in node-positive disease. Considering subdivisions within luminal disease, the Panel was more concerned with indications for the use of specific therapies, rather than surrogate identification of intrinsic subtypes as measured by multiparameter molecular tests. For the treatment of HER2-positive disease in patients with node-negative cancers up to 1 cm, the Panel endorsed a simplified regimen comprising paclitaxel and trastuzumab without anthracycline as adjuvant therapy. For premenopausal patients with endocrine responsive disease, the Panel endorsed the role of ovarian function suppression with either tamoxifen or exemestane for patients at higher risk. The Panel noted the value of an LHRH agonist given during chemotherapy for premenopausal women with ER-negative disease in protecting against premature ovarian failure and preserving fertility. The Panel noted increasing evidence for the prognostic value of commonly used multiparameter molecular markers, some of which also carried prognostic information for late relapse. The Panel noted that the results of such tests, where available, were frequently used to assist decisions about the inclusion of cytotoxic chemotherapy in the treatment of patients with luminal disease, but noted that threshold values had not been established for this purpose for any of these tests. Multiparameter molecular assays are expensive and therefore unavailable in much of the world. The majority of new breast cancer cases and breast cancer deaths now occur in less developed regions of the world. In these areas, less expensive pathology tests may provide valuable information. The Panel recommendations on treatment are not intended to apply to all patients, but rather to establish norms appropriate for the majority. Again, economic considerations may require that less expensive and only marginally less effective therapies may be necessary in less resourced areas. Panel recommendations do not imply unanimous agreement among Panel members. Indeed, very few of the 200 questions received 100% agreement from the Panel. In the text below, wording is intended to convey the strength of Panel support for each recommendation, while details of Panel voting on each question are available in supplementary Appendix S2, available at Annals of Oncology online. - †See Appendix for the list of Panel Members. introduction The fourteenth St Gallen International Breast Cancer Conference, held for the first time in neighboring Vienna, Austria, confirmed, and extended the recommendations of earlier reports. This report is focused on providing a practical approach to the allocation of available therapies to individual patients in the light of the most recent (...truncated)


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Coates, A. S., Winer, E. P., Goldhirsch, A., Gelber, R. D., Gnant, M., Piccart-Gebhart, M., Thürlimann, B., Senn, H.-J., André, Fabrice, Baselga, José, Bergh, Jonas, Bonnefoi, Hervé, Burstein, Harold, Cardoso, Fatima, Castiglione-Gertsch, Monica, Coates, Alan S., Colleoni, Marco, Curigliano, Giuseppe, Davidson, Nancy E., Di Leo, Angelo, Ejlertsen, Bent, Forbes, John F., Galimberti, Viviana, Gelber, Richard D., Gnant, Michael, Goldhirsch, Aron, Goodwin, Pamela, Harbeck, Nadia, Hayes, Daniel F., Huober, Jens, Hudis, Clifford A., Ingle, James N., Jassem, Jacek, Jiang, Zefei, Karlsson, Per, Morrow, Monica, Orecchia, Roberto, Kent Osborne, C., Partridge, Ann H., de la Peña, Lorena, Piccart-Gebhart, Martine J., Pritchard, Kathleen I., Rutgers, Emiel J.T., Sedlmayer, Felix, Semiglazov, Vladimir, Shao, Zhi-Ming, Smith, Ian, Thürlimann, Beat, Toi, Masakazu, Tutt, Andrew, Viale, Giuseppe, von Minckwitz, Gunter, Watanabe, Toru, Whelan, Timothy, Winer, Eric P., Xu, Binghe. Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015, Annals of Oncology, 2015, pp. 1533-1546, Volume 26, Issue 8, DOI: 10.1093/annonc/mdv221