Breast cancer: a global perspective

The 2001 American Society of Clinical Oncology (ASCO) International Symposium, Breast Cancer: A Global Perspective, was conducted by members of the ASCO International Committee and additional speakers from around the world. An interactive format was chosen to: (1) learn how patterns of incidence, epidemiology, and causal biology relate to breast cancer around the world; (2) discuss the challenges in screening, diagnosis, and treatment of breast cancer, as well as its socioeconomic impact in various regions; (3) describe international differences in approach to and management of advanced breast cancer; and (4) discuss treatment in terms of hormone response, clinical research, and drug metabolism. After a brief introduction, each speaker gave an overview of breast cancer challenges and issues in their country, and discussed how the following case might be diagnosed and treated: A 44-year-old mother who presents with a finding of a painless breast lump and no prior history of breast masses, trauma, or surgery. Comments from a patient perspective were then presented, followed by a panel discussion and closing remarks. Co-chairs of this Symposium included Deborah Collyar (President, PAIR-Patient Advocates in Research) and Elizabeth Eisenhauer, MD (Director, Investigational New Drug Program, National Cancer Institute of Canada Clinical Trials Group). Speakers included Gilberto Schwartsmann, MD (South America), Monica Morrow, MD (North America), Daniel Vorobiof, MD (South Africa), Rakesh Chopra, MD (India), Klaus Hoeffken, MD (Eastern Europe), Russell Basser, MD (Australia), Susan Matsuko Shinigawa (patient perspective), and Larry Norton, MD (closing remarks).

American Society of Clinical Oncology technology assessment on breast cancer risk reduction strategies: tamoxifen and raloxifene

OBJECTIVE

To conduct an evidence-based technology assessment to determine whether tamoxifen and raloxifene as breast cancer risk-reduction strategies are appropriate for broad-based conventional use in clinical practice.

POTENTIAL INTERVENTION

Tamoxifen and raloxifene.

OUTCOME

Outcomes of interest include breast cancer incidence, breast cancer-specific survival, overall survival, and net health benefits.

EVIDENCE

A comprehensive, formal literature review was conducted for tamoxifen and raloxifene on the following topics: breast cancer risk reduction; tamoxifen side effects and toxicity, including endometrial cancer risk; tamoxifen influences on nonmalignant diseases, including coronary heart disease and osteoporosis; and decision making by women at risk for breast cancer. Testimony was collected from invited experts and interested parties.

VALUES

More weight was given to publications that described randomized trials. BENEFITS/HARMS/COSTS: The American Society of Clinical Oncology (ASCO) Working Group acknowledges that a woman's decision regarding breast cancer risk-reduction strategies will depend on the importance and weight attributed to the information provided regarding both cancer and non-cancer-related risks.

CONCLUSIONS

For women with a defined 5-year projected risk of breast cancer of >/= 1.66%, tamoxifen (at 20 mg/d for up to 5 years) may be offered to reduce their risk. It is premature to recommend raloxifene use to lower the risk of developing breast cancer outside of a clinical trial setting. On the basis of available information, use of raloxifene should currently be reserved for its approved indication to prevent bone loss in postmenopausal women. Conclusions are based on single-agent use of the drugs. At the present time, the effect of using tamoxifen or raloxifene with other medications (such as hormone replacement therapy), or using tamoxifen and raloxifene in combination or sequentially, has not been studied adequately. The continuing use of placebo-controlled trials in other risk-reduction trials highlights the current unanswered issues concerning the use of such interventions, especially when the influence on net health benefit remains to be determined. Breast cancer risk reduction is a rapidly evolving area. This technology assessment represents an ongoing process with existing plans to monitor and review data and to update recommendations in a timely matter. (See

VALIDATION

The conclusions of the Working Group were evaluated by the ASCO Health Services Research Committee and by the ASCO Board of Directors.

SPONSOR

American Society of Clinical Oncology.