Comparison of 4th ESO-ESMO international consensus guidelines for advance breast cancer and Chinese anti-cancer association committee of Breast Cancer Society guideline

Development of a Preoperative Prediction Model Based on Spectral CT to Evaluate Axillary Lymph Node With Macrometastases in Clinical T1/2N0 Invasive Breast Cancer

OBJECTIVES

To develop a prediction model based on spectral computed tomography (CT) to evaluate axillary lymph node (ALN) with macrometastases in clinical T1/2N0 invasive breast cancer.

METHODS

A total of 217 clinical T1/2N0 invasive breast cancer patients who underwent spectral CT scans were retrospectively enrolled and categorized into a training cohort (n = 151) and validation cohort (n = 66). These patients were classified into ALN nonmacrometastases (stage pN0 or pN0 [i+] or pN1mi) and ALN macrometastases (stage pN1-3) subgroups. The morphologic criteria and quantitative spectral CT parameters of the most suspicious ALN were measured and compared. Least absolute shrinkage and selection operator (Lasso) was used to screen predictive indicators to build a logistic model. The receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to evaluate the models.

RESULTS

The combined arterial-venous phase spectral CT model yielded the best diagnostic performance in discrimination of ALN nonmacrometastases and ALN macrometastases with the highest AUC (0.963 in the training cohort and 0.945 in validation cohorts). Among single phase spectral CT models, the venous phase spectral CT model showed the best performance (AUC = 0.960 in the training cohort and 0.940 in validation cohorts). There was no significant difference in AUCs among the 3 models (DeLong test, P > .05 for each comparison).

CONCLUSION

A Lasso-logistic model that combined morphologic features and quantitative spectral CT parameters based on contrast-enhanced spectral imaging potentially be used as a noninvasive tool for individual preoperative prediction of ALN status in clinical T1/2N0 invasive breast cancers.

Therapy for Hormone Receptor-Positive, Human Epidermal Growth Receptor 2-Negative Metastatic Breast Cancer Following Treatment Progression via CDK4/6 Inhibitors: A Literature Review

Endocrine therapy (ET) with a cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) is currently the first-line standard treatment for most patients with hormone receptor-positive (HR+) and human epidermal growth receptor 2-negative (HER2-) metastatic or advanced breast cancer. However, the majority of tumors response to and eventually develop resistance to CDK4/6is. The mechanisms of resistance are poorly understood, and the optimal postprogression treatment regimens and their sequences continue to evolve in the rapidly changing treatment landscape. In this review, we generally summarize the mechanisms of resistance to CDK4/6is and ET, and describe the findings from clinical trials using small molecule inhibitors, antibody-drug conjugates and immunotherapy, providing insights into how these novel strategies may reverse treatment resistance, and discussing how some have not translated into clinical benefit. Finally, we provide rational treatment strategies based on the current emerging evidence.

Comparison of two regimens of weekly paclitaxel plus gemcitabine in patients with metastatic breast cancer: propensity score-matched analysis of real-world data

Purpose

Weekly gemcitabine + paclitaxel (wGT) administration is widely applied in real-world clinical practice. The 28-day and 21-day regimens of wGT are the most widely accepted regimens. We evaluated the efficacy and safety of wGT administration in patients with metastatic breast cancer (MBC) and compared the two regimens.

Methods

Patients with human epidermal growth factor receptor 2 (HER-2)-negative MBC who received wGT between October 2013 and October 2016 were identified using an electronic database. The outcome variables included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and safety profile. Propensity score matching was performed to minimize potential confounders.

Results

A total of 140 patients were included. The median PFS and OS was 7.8 [95% confidence interval (CI) = 7.0-8.7] months and 22.5 (95% CI = 18.8-26.1) months, respectively. The toxicity of wGT was manageable. Among the patients, 90 (64.3%) received the 21-day regimen and 50 (35.7%) received the 28-day regimen. A higher number of younger patients and patients receiving later-line therapy received the 28-day regimen. There was no significant difference between the two groups in PFS after propensity score matching, though subgroup analysis showed that patients with early relapse benefited more from the 28-day regimen. The ORR was numerically higher in 28-day regimen (37.8% versus 28.0%, p = 0.310). However, the 21-day regimen was better tolerated than the 28-day regimen.

Conclusion

wGT administration showed efficacy and safety in patients with MBC. The efficacy was comparable between the two regimens after adjustment for confounding factors while the 21-day regimen was better tolerated.

Plain Language Summary

21-day regimen of wGT was well tolerated in patients with metastatic breast cancer Weekly gemcitabine + paclitaxel (wGT) administration is widely applied in real-world clinical practice. The 28-day and 21-day regimens of wGT are the most widely accepted regimens. We evaluated the efficacy and safety of wGT administration in patients with metastatic breast cancer (MBC) and compared the two regimens. Patients with human epidermal growth factor receptor 2 (HER-2)-negative MBC who received wGT between October 2013 and October 2016 were identified using an electronic database. The outcome variables included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and safety profile. Propensity score matching was performed to minimize potential confounders. We found that the efficacy was comparable between the two regimens after adjustment for confounding factors while the 21-day regimen was better tolerated.

New Zealand experience with implementation of the ESO-ESMO consensus guidelines for advanced breast cancer-report of achievements and lessons learned

BACKGROUND

People with advanced breast cancer (ABC) in New Zealand (NZ) have a poorer five-year survival than their peers in other developed countries. Comparisons of ABC care in NZ with other countries suggest that NZ is sometimes out of line with international standards and that inequities exist within the NZ healthcare system. Our aim was to develop nationwide consensus guidelines for diagnosis and treatment of ABC that are uniquely suited for the NZ context and can be applied across the nation. We describe the process of creating, voting on, and disseminating the guidelines, and provide insight into how we can better optimize these processes for the NZ context in the future.

METHODS

The ABC5 ESO-ESMO consensus guidelines were used and adapted to the NZ clinical context. A panel of breast cancer clinicians voted on these guidelines using the same model of membership representation as ABC5.

OUTCOME

Overall consensus was equally high between ABC5 and ABC-NZ. Four NZ specific guidelines were introduced. The European-style panel discussion needs some adaptations for the NZ situation and a wider and more thorough consultation process, before voting begins, is preferred. The NZ Breast Special Interest Group has endorsed and agreed to take ownership of these and future guidelines and to facilitate the next iteration of the ABC-NZ guidelines meeting.

CONCLUSIONS

The process was successful in creating the guidelines but can be improved in future meetings to streamline the process of creating and updating guidelines in the manner most suited to the NZ context and audience.

Spatiotemporal Patterns of Loco-Regional Recurrence After Breast-Conserving Surgery

Background

Loco-regional recurrences (LRR) following breast-conserving surgery (BCS) remain a heterogeneous class of disease that has significant variation in its biological behavior and prognosis.

Methods

To delineate the spatiotemporal patterns of LRR after BCS, we analyzed the data of 4325 patients treated with BCS from 2006 to 2016. Clinico-pathological and treatment specific factors were analyzed using the Cox proportional hazards model to identify factors predictive for LRR events. Recurrence patterns were scrutinized based on recurrence type and recurrence-free interval (RFI). Annual recurrence rates (ARR) were compared according to recurrence type and molecular subtype.

Results

With a median follow-up of 66 months, 120 (2.8%) LRRs were recorded as the first site of failure. Age, pathologic stage, and molecular subtype were identified as predictors of LRR. The major recurrence type was ipsilateral breast tumor recurrence, which mainly (83.6%) occurred ≤5y post surgery. In the overall population, ARR curves showed that relapse peaked in the first 2.5 years. Patients with regional nodal recurrence, shorter RFI, and synchronous distant metastasis were associated with a poorer prognosis. HER2-positive disease had a higher rate of LRR events, more likely to have in-breast recurrence, and had an earlier relapse peak in the first 2 years after surgery.

Conclusions

LRR risk following BCS is generally low in Chinese ethnicity. Different recurrence patterns after BCS were related to distinct clinical outcomes. Management of LRR should be largely individualized and tailored to the extent of disease, the molecular profile of the recurrence, and to baseline clinical variables.

Advances in endocrine and targeted therapy for hormone-receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer

Nearly 70% of breast cancer (BC) is hormone-receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, and endocrine therapy is the mainstay of treatment for this subtype. However, intrinsic or acquired endocrine resistance can occur during the endocrine treatment. Based on insights of endocrine resistance mechanisms, a number of targeted therapies have been and continue to be developed. With regard to HR-positive, HER2-negative advanced BC, aromatase inhibitor (AI) is superior to tamoxifen, and fulvestrant is a better option for patients previously exposed to endocrine therapy. Targeted drugs, such as cyclin-dependent kinases (CDK) 4/6 inhibitors, mammalian target of rapamycin (mTOR) inhibitors, phosphoinositide-3-kinase (PI3K) inhibitors, and histone deacetylase (HDAC) inhibitors, play a significant role in the present and show a promising future. With the application of CDK4/6 inhibitors becoming common, mechanisms of acquired resistance to them should also be taken into consideration.

Long-Term Results of Partial Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer: A Prospective Phase II Trial in China

Background

Partial breast radiotherapy (PBI) has emerged as an option after breast-conserving surgery for early stage breast cancer patients.

Methods

A total of 55 patients with early stage breast cancer between 2009 and 2013 were enrolled in this single-institutional phase II prospective clinical trial. All patients received adjuvant PBI-IMRT after lumpectomy, with the prescription of 48 Gy in 12 fractions at 4 Gy per fraction, 5 days a week. The primary endpoint was ipsilateral breast tumor recurrence (IBTR), the other endpoints were a regional nodal failure (RNF), distant metastasis (DM) rate, disease-free survival (DFS), and overall survival (OS). These endpoints were used to evaluate clinical outcomes. The cosmetic effects and the late toxicity were assessed according to Harvard standard scale and CTCAE 3.0, respectively.

Results

In our cohorts, the median age was 45.60 years old (range 31-65 years) and 29.09% of these patients were post-menopause (n = 16). Most patients were T1 stage (65.45%) or N0 stage (70.91%). 80% of patients were ER-positive, 67.27% PR positive, and 61.82% HER2 negative. At the median follow-up of 9.25 years, RNF was 0% and IBTR occurred in only one patient (1.82%) to the chest wall. Except for one patient (1.82%) had DM to lung and pleura and died from disease progression, the remaining patients were alive at the end of the 10-year follow-up. The 10-year DFS and OS were 94.55 and 98.18%. One patient (1.82%) was diagnosed with endometrial cancer after PBI. Except for 9 patients who declined the cosmetic assessment, the rest of the 46 patients (83.64%) were all rated as good and well-satisfied with the appearance of the irradiated breast. No breast retraction and fibrosis were observed in any of the patients. Additionally, only 4 patients experienced grade 1 late toxicity (7.28%). None had grade 3 or higher late toxicity.

Conclusion

This is the first study to report the 10-year results of PBI after breast-conserving surgery in Chinese patients. Our study suggested that PBI had durable local control and maintained good cosmetic outcomes with minimal late toxicity at long term follow up for the early stage breast cancer patients.

Comparison of the clinicopathological characteristics and prognosis between Chinese patients with breast cancer with bone-only and non-bone-only metastasis

Bone is the most common site of metastatic spread in patients with breast cancer. Patients with bone-only metastasis (BOM) are a unique group. The aim of the present study was to compare the clinicopathological characteristics, survival and prognostic factors of patients with BOM and non-BOM. The clinical data of 1,290 patients with metastatic breast cancer treated at the Tianjin Medical University Cancer Institute and Hospital (Tianjin, China) between January 2008 and December 2017 were reviewed. The clinical data were divided into a BOM group (n=208 cases) and a non-BOM group (n=1,082 cases). Patients with BOM had longer disease-free survival, progression-free survival (PFS) and overall survival (OS) compared with patients in the non-BOM group. The hormone receptor (HR) status and number of metastases were significant influencing factors of PFS in the BOM group. Furthermore, the HR status, location of bone metastasis and number of bone metastases were significantly associated with OS of patients in the BOM group. Age at diagnosis of metastasis, HR status and tumor stage were significantly associated with OS in the non-BOM group. In the BOM group, patients with HR⁺/human epidermal growth factor receptor 2 (HER2)⁻ tumors had the most favorable prognosis. In the non-BOM group, patients with HR⁺/HER2⁻ and HER2⁺ tumors had improved prognosis. In the BOM with HR⁺/HER2⁻ subgroup, the PFS and OS of patients receiving endocrine therapy or sequential therapy (chemotherapy followed by endocrine therapy) was significantly improved compared with those receiving chemotherapy alone (P<0.05). Skeletal-related events were significantly associated with the number of bone metastases (P<0.001). The most common secondary metastatic site in the BOM group was the liver. The prognosis of the patients in the BOM group was improved compared with that in the non-BOM patients. HR⁻ and multiple bone metastases, as well as combined axial and appendicular bone metastases, were significantly associated with poor prognosis in the patients with BOM. For patients in the HR⁺/HER2⁻ BOM subgroup, endocrine therapy alone resulted in satisfactory results.