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| Left: Dr. Peng Yuan, Center: Dr. Binghe Xu, Right: Dr. Guohong Song Title: "China Diagnosis and Treatment Expert Consensus in Advanced BC" Lecture Source: Oncology Frontier(肿瘤瞭望) |
"China Diagnosis and Treatment Expert Consensus in Advanced Breast Cancer" was released on April 23, 2015, written by Chinese Breast Cancer Society of Chinese Anti-cancer Society.
Consensus "Endocrine Therapy" for pre-menopausal breast cancer patients are the focused discussion by the panelists: Bing-He Xu, MD, PhD, Professor, Yuan Peng, MD, Professor and Guo-Hong song, MD, Professor.
Dr. Peng Yuan: First edition of ESO-ESMO advanced breast cancer expert consensus (ABC1) published in 2012. In September 2014 the second ESO - ESMO advanced breast cancer international consensus guidelines (revised) "was published, this is international experts consensus about locally advanced and metastatic breast cancer treatment.
In order to standardize the diagnosis and treatment of advanced breast cancer in China, the consensus editorial committee has collaborated with specialists from multiple disciplinary(lab, imaging, pathology and breast cancer oncologist, etc.).
The first consensus was written according to the specific circumstances of China, focusing metastatic breast cancer. Local, advanced breast cancer may be covered later in second version and third version.
China consensus is different from international ones, in scope of disease coverage.
As long as hormone receptor(HR) positive , and patients don't have internal organ crisis, and then endocrine therapy is given preference.
Endocrine therapy has mild impact on quality of life; has same survival benefit compared with chemotherapy are similar. Its survival benefit is longer than chemo on suitable patients. for the remission or longer (chemotherapy: 4 ~ 5 months; endocrine therapy, once is effective, could be up to 10 ~ 12 months).
International Consensus seems to more emphasize at the role of endocrine therapy.
The "ESO - ESMO Advanced Breast Cancer International Consensus Guidelines" has released two editions, and China released first time of its' Consensus (ABC-China). What is the difference between the two?
In order to standardize the diagnosis and treatment of advanced breast cancer in China, the consensus editorial committee has collaborated with specialists from multiple disciplinary(lab, imaging, pathology and breast cancer oncologist, etc.).
The first consensus was written according to the specific circumstances of China, focusing metastatic breast cancer. Local, advanced breast cancer may be covered later in second version and third version.
China consensus is different from international ones, in scope of disease coverage.
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| Bing-He Xue, MD PhD Professor Director, Clinical Oncology Department Cancer Hospital Chinese Medical Science Acedamy Chairman, Chinese Breast Cancer Society Source: Oncology Frontier(肿瘤瞭望) |
Dr. Bing-He Xu: China Consensus and International Consensus are in common in most parts, both emphasize at endocrine therapy.
As long as hormone receptor(HR) positive , and patients don't have internal organ crisis, and then endocrine therapy is given preference.
Endocrine therapy has mild impact on quality of life; has same survival benefit compared with chemotherapy are similar. Its survival benefit is longer than chemo on suitable patients. for the remission or longer (chemotherapy: 4 ~ 5 months; endocrine therapy, once is effective, could be up to 10 ~ 12 months).
International Consensus seems to more emphasize at the role of endocrine therapy.
Chemotherapy or endocrine therapy, which one should be preferred for HR positive, pre-menopausal, advanced breast cancer patients?
Dr. Guo-Hong Song: Chemotherapy or endocrine therapy? The preference should be based on patient's specific condition.
Endocrine therapy is preferred, If the patient' s disease-free survival expectancy is long, HR positive, with bone and lymph node metastases, no symptoms of internal organ metastasis, etc., and has slow disease progression. As for the proportion of endocrine therapy, it depends on how many suitable patients are there. About 50% ~ 60% patients will be preferred to endocrine therapy, and 40% ~ 50% patients for chemotherapy.
The problem is, some oncologists in the basic-level hospitals will give chemotherapy to patients actually suitable for endocrine, which patient will have small benefit, yet serious side effect.
So it is very important to promote the Consensus, comprehensively.
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| Peng Yuan, MD Professor Department of Clinical Oncology Cancer Hospital Chinese Medical Science Academy Source: Oncology Frontier(肿瘤瞭望) |
Dr. Yuan: Some physicians and patients' misunderstanding about endocrine therapy needs to be the corrected.
Some patients don't think oral endocrine drugs can treat this severe breast cancer disease, and they expect to use chemotherapy to control the cancer fast. Whereas some clinicians may not have deep understanding of the standard of care, mistakenly chose chemotherapy to put patients on lots of pain instead of effective treatment.
Dr. Song: Endocrine therapy is very effective in suitable patients. Physicians should have confidence, and to pass the confidence to patients.
How to choose suitable patients for endocrine therapy? Endocrine drugs consists of ovarian suppression agents, tamoxifen, aromatase inhibitors (AI), toremifene, what are the reasons to choose endocrine drugs?
Dr. Song: This patient(Case details omitted) has long disease free survival. After 10 years, her cancer recurred, with metastatic lesions as small lung nodule, pleural effusion. So she has slow disease progression, very suitable for endocrine therapy indication.
She is premenopausal, already used tamoxifen in the past, so the first thing is to give her ovarian suppression therapy, and drug castration is relatively safe and effective.
The patient finished tamoxifen therapy more than 5 years ago, so tamoxifen therapy may be still be effective, but in order to ensure the efficacy, we recommended AI treatment for her.
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| Guohong Song, MD Professor Breast Cancer Internal Medicine Department Cancer Hospital Beijing University Source: Oncology Frontier(肿瘤瞭望 |
Dr. Xu: Professor Yuan, do you think the patient can choose radiotherapy castration or surgical castration?
Dr. Yuan: Currently, radiation castration has been rarely used. The reasons, radiotherapy castration effect is not complete, and can cause abdominal injury.
Surgical castration is an option, but the effect of surgical castration is permanent, which reduce the patient's quality of life, has a great influence on the patients' psychology health. Doctors can negotiate with the patient whether to choose surgery or drug castration.
Dr. Xu: If premenopausal, advanced breast cancer patients are suitable for endocrine therapy, but not sure about the efficacy, can first choose drug castration + other endocrine therapy drug treatment for about 3 months.
If good effect is proved, then the tumor is endocrine therapy reactive, and continue endocrine therapy (surgical castration or drug castration + AI/tamoxifen, etc.). However, the surgical castration is unrecoverable, so to take the quality of patients life into consideration, drug castration is recommended.
Endocrine treatment in ER positive and/or HER2 negative patients
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| Left: Dr. Peng Yuan, Center: Dr. Binghe Xu, Right: Dr. Guohong Song Title: "China Diagnosis and Treatment Expert Consensus in Advanced BC" Lecture Source: Oncology Frontier(肿瘤瞭望) |
After effective chemo, when to choose maintain with chemo, when to choose maintain with endocrine therapy?
Dr. Yuan: It depends on curative effect of chemotherapy. If disease progresses quickly, and with multiple lesions, to choose single oral chemo agent is effective and reasonable.
But in most cases after several cycles of chemotherapy, if the disease has been under good control, less lesions, without obvious symptoms, we can choose endocrine therapy as maintenance.
Endocrine therapy can be put on a long time, many patients can't tolerate maintenance chemotherapy, may not be able to benefit it's efficacy.
Dr. Song: I agree with professor Yuan. If patients' chemotherapy effect is very good, tolerate well, chemo is recommended. Multiple agents combination chemo could be changed to single-agent.
If chemotherapy only is able to stabilize the progression , then there is no point to use chemo, patients will benefit more from endocrine therapy
Dr. Xu: What kind of maintenance regimen to use should based on their efficacy and toxicity profile.
Dr. Yuan: Chemotherapy, if effective, it is necessary to keep it as maintenance treatment. As for HR positive patients, which maintenance treatment to use is always in debate. Recommendation should be based on the patient's own situation.
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