To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer.
ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy ...for breast cancer and provide recommended care options.
A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations.
Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.Additional information is available at www.asco.org/breast-cancer-guidelines.
To update recommendations of the ASCO systemic therapy for hormone receptor (HR)-positive metastatic breast cancer (MBC) guideline.
An Expert Panel conducted a systematic review to identify new, ...potentially practice-changing data.
Fifty-one articles met eligibility criteria and form the evidentiary basis for the recommendations.
Alpelisib in combination with endocrine therapy (ET) should be offered to postmenopausal patients, and to male patients, with HR-positive, human epidermal growth factor receptor 2 (HER2)-negative,
-mutated, ABC, or MBC following prior endocrine therapy with or without a cyclin-dependent kinase (CDK) 4/6 inhibitor. Clinicians should use next-generation sequencing in tumor tissue or cell-free DNA in plasma to detect
mutations. If no mutation is found in cell-free DNA, testing in tumor tissue, if available, should be used as this will detect a small number of additional patients with
mutations. There are insufficient data at present to recommend routine testing for
mutations to guide therapy for HR-positive, HER2-negative MBC. For
or
mutation carriers with metastatic HER2-negative breast cancer, olaparib or talazoparib should be offered in the 1st-line through 3rd-line setting. A nonsteroidal aromatase inhibitor (AI) and a CDK4/6 inhibitor should be offered to postmenopausal women with treatment-naïve HR-positive MBC. Fulvestrant and a CDK4/6 inhibitor should be offered to patients with progressive disease during treatment with AIs (or who develop a recurrence within 1 year of adjuvant AI therapy) with or without one line of prior chemotherapy for metastatic disease, or as first-line therapy. Treatment should be limited to those without prior exposure to CDK4/6 inhibitors in the metastatic setting.Additional information can be found at www.asco.org/breast-cancer-guidelines.
To develop recommendations concerning the management of male breast cancer.
ASCO convened an Expert Panel to develop recommendations based on a systematic review and a formal consensus process.
...Twenty-six descriptive reports or observational studies met eligibility criteria and formed the evidentiary basis for the recommendations.
Many of the management approaches used for men with breast cancer are like those used for women. Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy should be offered tamoxifen for an initial duration of five years; those with a contraindication to tamoxifen may be offered a gonadotropin-releasing hormone agonist/antagonist plus aromatase inhibitor. Men who have completed five years of tamoxifen, have tolerated therapy, and still have a high risk of recurrence may be offered an additional five years of therapy. Men with early-stage disease should not be treated with bone-modifying agents to prevent recurrence, but could still receive these agents to prevent or treat osteoporosis. Men with advanced or metastatic disease should be offered endocrine therapy as first-line therapy, except in cases of visceral crisis or rapidly progressive disease. Targeted systemic therapy may be used to treat advanced or metastatic cancer using the same indications and combinations offered to women. Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy regardless of genetic predisposition; contralateral annual mammogram may be offered to men with a history of breast cancer and a genetic predisposing mutation. Breast magnetic resonance imaging is not recommended routinely. Genetic counseling and germline genetic testing of cancer predisposition genes should be offered to all men with breast cancer.
Background
To determine long‐term quality‐of‐life (QOL) trajectories among breast cancer survivors aged 65+ (older) evaluating the effects of personality and social support.
Methods
Older women ...(N = 1280) newly examined with invasive, nonmetastatic breast cancer completed baseline assessments. Follow‐up data were collected 6 and 12 months later and then annually for up to 7 years (median 4.5 years). Quality of life was assessed using EORTC‐QLQ‐C30 emotional, physical, and cognitive scales. Optimism (Life Orientation Test), Coping (Brief COPE), and social support (Medical Outcomes Study) were assessed at baseline. Group‐based trajectory modeling identified QOL trajectories; multinomial regression evaluated effects of predictors on trajectory groups. Age, education, systemic therapy, comorbidity, and reported precancer function (SF‐12) were considered as controlling variables.
Results
Three trajectories were identified for each QOL domain: “maintained high,” “phase shift” (lower but parallel scores to “maintained high” group), and “accelerated decline” (lowest baseline scores and steepest decline). Accelerated decline in emotional, physical, and cognitive function was seen in 6.9%, 31.8%, and 7.6% of older survivors, respectively. Maladaptive coping and lower social support increased adjusted odds of being in the accelerated decline group for all QOL domains; lower optimism was only related to decline in emotional function. Chemotherapy was related to physical and cognitive but not emotional function trajectories.
Conclusions
Personality and social resources affect the course of long‐term emotional well‐being of older breast cancer survivors; treatment is more important for physical and cognitive than emotional function. Early identification of those vulnerable to deterioration could facilitate clinical and psychological support.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Incorporation of an aromatase inhibitor is superior to tamoxifen alone for postmenopausal women.1 Guidelines recommend aromatase inhibitor either upfront or as part of an early switch strategy after ...2–3 years of tamoxifen.2 Recommendations on extended adjuvant endocrine therapy after 5 years are evolving. Other trials evaluating an aromatase inhibitor after 5 years of tamoxifen showed similar HR point estimates of 0·57–0·62.2 These data were included in a preliminary Early Breast Cancer Trials Collaborative Group (EBCTCG) meta-analysis7 that reported a 35% reduction in recurrence with 5 years of aromatase inhibitor after tamoxifen with a conclusion that longer follow-up would be needed. ...long-term results from the DATA trial and the EBCTCG become available, the currently available data seem to recommend 5 years of aromatase inhibitor for postmenopausal women who have already completed 2–3 years of tamoxifen. ...with 685 000 global breast cancer deaths annually, we need to strive for better treatments.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Women with germline BRCA1 or BRCA2 (BRCA) mutations, are recommended risk-reducing salpingo-oophorectomy (RRSO) prior to menopause. Surgical menopause has significant impact on patients' health and ...well–being. Subsequently, concerns about surgical menopause influence uptake of RRSO in high risk women. The role of hormone replacement therapy (HRT) in BRCA mutation carriers undergoing RRSO has been controversial. In the general population, premature surgical menopause is associated with worse quality of life and cognitive function, and increased risk of bone and cardiovascular disease; HRT continued until the natural age of menopause is shown to alleviate a number of these effects. Conflicting information has been published on HRT and breast cancer risk. For BRCA mutation carriers, potential augmentation of already elevated breast cancer risk is of great concern. In this article, we provide a review of the literature on HRT in this high-risk population, including effects on quality of life, cardiovascular, bone, and brain health. We also review impact of HRT on breast cancer risk, with a discussion of HRT formulation and surgical approach. Though evidence is limited, HRT after RRSO has a number of reported benefits and does not appear to impact breast cancer risk reduction in BRCA mutation carriers. This information is critical when discussing RRSO with patients, as providers should review risks of early menopause and treatment options. This review provides information to assist with counseling this specific population.
•Hormone replacement therapy use improves endocrine symptoms and sexual function after premature surgical menopause.•In BRCA mutation carriers, breast cancer risk is not altered by estrogen replacement therapy after oophorectomy.•Progestin containing hormonal regimens may have a less favorable breast cancer risk profile for BRCA mutation carriers.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Exercise after breast cancer diagnosis is associated with lower cancer-specific mortality, but the biological mechanisms through which exercise impacts breast cancer are not fully understood. The ...Pre-Operative Health and Body (PreHAB) Study was a randomized window-of-opportunity trial designed to test the impact of exercise on Ki-67, gene expression, and other biomarkers in women with breast cancer.
Inactive women with newly diagnosed breast cancer were randomized to an exercise intervention or mind-body control group, and participated in the study between enrollment and surgery (mean 29.3 days). Tumor and serum were collected at baseline and surgery.
Forty-nine women were randomized (27 exercise, 22 control). At baseline, mean age was 52.6, body mass index was 30.2 kg/m
, and exercise was 49 minutes/week. Exercise participants significantly increased exercise versus controls (203 vs. 23 minutes/week,
< 0.0001). There were no differences in changes of expression of Ki-67, insulin receptor, and cleaved caspase-3 in exercise participants versus controls. KEGG pathway analysis demonstrated significant upregulation of 18 unique pathways between the baseline biopsy and surgical excision in exercise participants and none in control participants (
< 0.1). Top-ranked pathways included several implicated in immunity and inflammation. Exploratory analysis of tumor immune infiltrates demonstrated a trend toward a decrease in FOXP3
cells in exercise versus control participants over the intervention period (
= 0.08).
A window-of-opportunity exercise intervention did not impact proliferation but led to alterations in gene expression in breast tumors, suggesting that exercise may have a direct effect on breast cancer.
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Abstract
Background
Decreased mammography drives breast cancer disparities. Black women have lower rates of mammography completion than White women, and this contributes to disparities in outcomes. ...Points of disparity along the continuum for screening mammography remain underresearched.
Methods
The authors compared mammography referrals for Black and White women aged 40–74 years at a heterogeneous academic medical center. Completion of steps of the screening mammography continuum was compared between Black and White women within two age cohorts: 40–49 and 50–74 years. Multivariable logistic regression was used to evaluate the association between race and mammogram completion.
Results
Among 26,476 women, 3090 (12%) were Black, and 23,386 (88%) were White. Among Black women aged 50–74 years who were due for mammography, 40% had referrals, 39% were scheduled, and 21% completed mammography; the corresponding values for White women were 42%, 41%, and 27%, respectively. Similar differences in referral outcomes were noted for women aged 40–49 years, although Black women had lower rates of provider‐initiated referrals (9% vs. 13%). Adjusted analyses for those aged 40–49 and 50–74 years demonstrated an association between Black race and lower rates of mammography completion (odds ratio OR for 40–49 years, 0.74; 95% CI, 0.57–0.95;
p
= .02; OR for 50–74 years, 0.85; 95% CI, 0.74–0.98;
p
= .02). In multivariable analyses, noncommercial insurance and higher comorbidity were associated with lower rates of mammography. Provider‐initiated referral was positively correlated to mammogram completion.
Conclusions
Black race was associated with 15%–26% lower mammography completion (adjusted). Both groups experienced the highest attrition after scheduling mammograms, although attrition was more precipitous for Black women. These findings have implications for future interventions, including increasing provider‐initiated referrals and decreasing barriers to attending scheduled mammograms.
Black race was associated with 15%–26% lower mammography completion (adjusted), and Black women experienced the highest attrition after scheduling mammograms. These findings have implications for future interventions, including increasing provider‐initiated referrals and decreasing barriers to attending scheduled mammograms.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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