化学療法

St.Gallen乳癌初期治療に関する
コンセンサスカンファレンス

International Consensus Conference on Primary Treatment of Breast Cancer 2015

速報!パネリスト投票結果 2015. 3.24
一部不明なところもあり、誤りがありましたらお知らせ下さい。
初めの方は、投票装置のトラブルのトラブルで、パネラー49人が挙手をして、数えるという事態になりました。
また、Eric Winer先生のアドリブで設問が変更されたり、新規に作ったりと、ついて行けなくなっているところもあり、
大変分かりづらいところも多いかと思いますが、ご勘弁下さい。

 

St. Gallen Oncology Conference

1.     Surgery of the Primary

l  In women undergoing breast conserving surgery for invasive BC and proceeding to standard radiation and adjuvant systemic therapy the minimum acceptable surgical margin is:

1)       No ink on invasive tumor      75%                91.9%

2)       1-2 mm clearance?             25%                 8.1%

3)       >2-5 mm clearance               0                   0

4)       Margin is irrelaevant?           0                    0

9)       Abstain                               0                    0

l  Multifocal (unilateral) tumors can be treated with breast conservation provided margins are clear and whole RT is planned.

1)       Yes                            

2)       No                             

9)       Abstain

l  Multicentric (unilateral) tumors can be treated with breast conservation provided margins are clear and whole RT is planned.

1)       Yes                            

2)       No                             

9)       Abstain

l  Should the margin required be dependent on tumor biology?

2)  No

l  Should the margin required be greater if age < 40?

2)  No

l  Should the margin required be greater if lobular?

2)  No

l  Should the margin required be greater after neoadjuvant therapy?

2)  No

l  Should required margin be greater in presence of extensive intraductal compeonent?

2)  No

l  Should required margin be greater for pure DCIS than for invasive disease?

1)       Yes  <  2)  No

2.     Surgery Following Neo-adjuvant Chemotherapy

In a patient who is clinically node positive at presentation who downstages after chemotherapy:

l  Is SN Biopsy appropriate?

1)        Yes  >  2)  No

l  Can ALND be avoided if 1 SN positive?

1)        Yes  25%  <  2)  No 75%

l  Can ALND be avoided if 2 SN positive?

2)  No

l  Can ALND be avoided if > 2 SN positive?

2)  No

Should the entire area of the original primary be resected after downstaging?

 

3.     Surgery of the Axilla

In patients with macro-metastases in 1-2 sentinel nodes, completion axillary dissection can safely be omitted following:

l  Mastectomy (no radiotherapy planned)

2)  No

l  Mastectomy (radiotherapy planned)

l  1)  Yes  <  2)  No

l  Conservative resection with radiotherapy using standard tangents

1)       Yes  80%  >  2)  No  20%

l  Conservative resection with radiotherapy using high tangents to include the lower axilla

1)        Yes  95%  >  2)  No 5%

 

4.     Partial Breast Irradiation

Following breast conserving surgery, partial breast irradiation may be used:

l  As the definitive irradiation, without whole breast irradiation in ASTRO/ESTRO “suitable” patients?

1)        Yes  85%  >  2)  No  10%  9)  Abstain  5%

l  As the definitive irradiation, without whole breast irradiation in ASTRO “cautionary” / ESTRO “intermediate” patients?

2)        No  >  9)  Abstain

l  Only in the absence of adverse tumor pathology?

(ASTRO/ESTRO guidelines allow any grade and are silent on multi-gene tests)

1)      Yes  <  2)  No  70%  >  9)  Abstain.

 

5.     Hypofractionated Breast Irradiation

Following breast conserving surgery, hypofractionated whole breast irradiation may be used in:

l  Patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement

1)        Yes  90%  9)  Abstain 5%

l  Patients younger than 50 years

1)      Yes  80%  9)  Abstain  20%

l  Those with prior chemotherapy or axillary lymph node involvement

1)      Yes  80%  9)  Abstain  20%

 

6.     Regional node irradiation: After Breast Conserving Surgery

l  Node positive

1)        Breast only

l  Node negative

1)      Breast only  0

2)      Breast + Regional node – IMN  60%

3)      Breast + Regional node + IMN  30%

9)      Abstain                                     10%

 

7.     Radiation Therapy: After Mastectomy

Should post mastectomy RT be standard for patients with:

l  T size >= 5 cm?

1)        Yes  95%  >  2)  No  5%

l  N+ 1 to 3 all patients?

1)      Yes  35%  2)  No  55%  9)  Abstain 10%

l  N+ 1 to 3 with adverse pathology?

1)      Yes  90%  2)  No  5%  9)  Abstain  5%

l  N+ 1 to 3 at young age (<40 yrs)?

1)      Yes  45%  2)  No  45%  9)  Abstain  10%

l  Positive sentinel node biopsy but no axillary dissection?

1)      Yes  90%  2)  No  5%  9)  Abstain  5%

l  Micrometastasis in sentinel node biopsy but no axillary dissection?

1)      Yes  <<  2)  No  95%  9) Abstain  5%

l  pN0 after axillary dissection without SNB and < 8 nodes examined?

1)      Yes  <<  2)  No  95%  9) Abstain  5%

 

8.     Radiation Therapy: After Mastectomy

Following mastectomy, radiation if given should include:

1)       Chest wall only                                        11.4%

2)       Chest wall and regional nodes but not IMN    40.9%

3)       Chest wall and regional nodes including IMN 15.9%

9)       Abstain                                                   31.8%

 

    If RT is given following immediate breast reconstruction, it should include:

l  Regional lymph node only

1)      Yes  13.3%  2)  62.2%  9)  24.4%

l  Nodes and the reconstructed breast:

Ÿ   In most cases

1)   Yes  54.8%  2)  No 28.5%  9)  Abstain  16.7%

Ÿ   Only with adverse pathological features

1)         Yes  37.5%  2)  No  42.5%  9)  Abstain  20%

 

9.     Radiation Following Neo-Adjuvant Chemotherapy

Approach to RT after neo-adjuvant therapy]

l  Should follow the stage before neo-adjuvant therapy?

1)        Yes  68.3%  2)  22%  9)  9.8%

l  Should follow the stage after neo-adjuvant therapy?

1)   Yes  24.4  2)  65.9%  9)  9.8%

 

10.  Pathology

Distinction between ‘Luminal A-live’ and ‘Luminal B-like’ (HER2 neg.) can be:

l  Derived from ER, PgR and Ki-67?

Ki-67 use requires knowledge of local lab values

1)        Yes  70.3%  2)  No  13.5%  9)  Abstain  13.5%

l  If used, the minimum value of Ki-67 required for ‘Luminal B-like’ is

1.  1 – 13 %                                                        2.3%

2.  14 – 19 %                                                    13.6%

3.  20 – 29 %                                                    36.4%

4.  30 % or more                                                6.8%

5.  Ki-67 should not be used for this distinction      20.5%

6.  Abstain                                                         2.3%

l  Only appropriately determined by multi-gene classifiers such as PAM50 or MammaPrint / BluePrint ?

1)      Yes  30.6%  2)  No  66.7%  9)  Abstain  2.8%

Subtype need not be determined since it can be replaced by risk scores derived from multi-gene tests

1)     Yes  26.2%  2)  No  59.5%  9)  Abstain  14.3%

Subtype need not be determined since it can be replaced by risk scores derived from multi-gene tests for chemotherapy in ER positive and HER2 negative, node negative

1)     Yes  55.6%  2)  No  44.4%  9) Abstain  0

    Should the extent of lymphocytic infiltration be reported and used as: A prognostic marker in TNBC and HER2 positive disease?

1)      Yes  25.6%  2)  No  69.8%  9) Abstain  4.7%

    Should the extent of lymphocytic infiltration be reported and used as: A predictive marker in TNBC and HER2 positive disease?

1)      Yes  7.7%  2)  No  89.7%  9) Abstain  2.6%

 

11.  Multi-Gene Signatures

In an endocrine-responsive cohort with high endocrine receptor level ±Ki-67 and negative HER2, clinically valuable additional information on prognosis and indication for chemotherapy is provided by:

l  Oncotype DX RS

Ÿ   Prognosis:  years 1 – 5 ?

1)  Yes  82.9%  2)  No  14.6%  9) Abstain  2.4%

Ÿ   Prognosis:  beyond 5 yrs ?

1)  Yes  43.9%  2)  No  51.2%  9) Abstain  4.9%

Ÿ   Chemotherapy ?

1)  Yes  80.5%  2)  No  14.6%  9) Abstain  4.9%

l  MammaPrint 70

Ÿ   Prognosis:  years 1 – 5 ?

1)  Yes  81%  2)  No  9.5%  9) Abstain  9.5%

Ÿ   Prognosis:  beyond 5 yrs ?

1)  Yes  19%  2)  No  66.7%  9) Abstain  14.3%

Ÿ   Chemotherapy ?

1)  Yes  35%  2)  No  47.5%  9) Abstain  17.5%

l  PAM-50 ROR score

Ÿ   Prognosis:  years 1 – 5 ?

1)  Yes  92.9%  2)  No  0%  9) Abstain  7.1%

Ÿ   Prognosis:  beyond 5 yrs ?

1)  Yes  63.2%  2)  No  18.4%  9) Abstain  18.4%

Ÿ   Chemotherapy ?

1)  Yes  38.2%  2)  No  47.1%  9) Abstain  14.7%

l  EndoPredict

Ÿ   Prognosis:  years 1 – 5 ?

1)  Yes  70.3%  2)  No  10.8%  9) Abstain  18.9%

Ÿ   Prognosis:  beyond 5 yrs ?

1)  Yes  38.2%  2)  No  38.2%  9) Abstain  23.5%

Ÿ   Chemotherapy ?

1)  Yes  23.5%  2)  No  52.9%  9) Abstain  23.5%

l  Breast Cancer Index

Ÿ   Prognosis:  years 1 – 5 ?

1)  Yes  58.3%  2)  No  8.3%  9) Abstain  33.3%

Ÿ   Prognosis:  beyond 5 yrs ?

1)  Yes  30.6%  2)  No  30.6%  9) Abstain  38.9%

Ÿ   Chemotherapy ?

1)  Yes  10%  2)  No  50%  9) Abstain  36.7%

 

12. Endocrine Therapy:  Premenopausal:  ‘Typical’ Cases

              Age 42, node negative, grade 2, T1, no chemotherapy:

1.     Tam alone                   85%

2.     OFS plus Tam            12.5%

3.  OFS plus AI               0

4.     None of the above      2.5%

9.     Abstain                       0

Age 34, node positive, grade 3, T1, remaining premenopausal after adjuvant chemotherapy:

1.     Tam alone                   2.3%

2.     OFS plus Tam            23.3%

3.     OFS plus exemestane  69.8%

4.     None of the above      2.3%

9.     Abstain                       2.3%

10.   

13.  Endocrine Therapy:  Premenopausal:  Selection Factors

Factors arguing for including ovarian function suppression (OFS) are:

Ÿ   Age <=35 years

1)  Yes  81%  2)  No  19%  9) Abstain  0%

Ÿ   Premenopausal oestrogen level after adjuvant chemotherapy

1)  Yes  73.7%  2)  No  26.3%  9) Abstain  0%

Ÿ   Grade 3

1)  Yes  55.9%  2)  No  38.2%  9) Abstain  0%

Ÿ   Involvement of 4 or more nodes

1)  Yes  89.7%  2)  No  10.3%  9) Abstain  0%

Ÿ   Adverse result of multi-gene test

1)  Yes  60%  2)  No  24.4%  9) Abstain  15.6%

 

14. Endocrine Therapy:  Premonopausal:  Selection Facors

              Factors arguing for use of OFS + AI rather than OFS + tamoxifen are:

Ÿ   Age <=35 years

1)  Yes  59.4%  2)  No  37.5%  9) Abstain  3.1%

Ÿ   Premenopausal oestrogen level after adjuvant chemotherapy

1)  Yes  43.9%  2)  No  51.2%  9) Abstain  4.9%

Ÿ   Grade 3

1)  Yes  92.5%  2)  No  5%  9) Abstain  2.5%

Ÿ   Involvement of 4 or more nodes

1)  Yes  65.8%  2)  No  31.5%  9) Abstain  2.6%

Ÿ   Adverse result of multi-gene test

1)  Yes  38.7%  2)  No  58.1%  9) Abstain  3.2%

 

15. Endocrine Therapy:  Postmenopausal

              Can some patients be adequately treated with tamoxifen alone?

1)  Yes  97.6%  2)  No  2.4%  9) Abstain  0%

              Factors arguing for inclusion of an AI at some pint are:

Ÿ   Age < 60

1)  Yes  31%  2)  No  69%  9) Abstain  0%

Ÿ   Involvement of 4 or more nodes

1)  Yes  97.6%  2)  No  2.4%  9) Abstain  0%

Ÿ   Grade 3 or high Ki-67

1)  Yes  97.7%  2)  No  2.3%  9) Abstain  0%

Ÿ   HER2 positivity

1)  Yes  71.1%  2)  No  28.9%  9) Abstain  0%

If and AI is used, should it be started upfront:

Ÿ   In all patients

1)  Yes  47.5%  2)  No  52.5%  9) Abstain  0%

Ÿ   In patients at higher risk?

1)  Yes  95.5%  2)  No  4.5%  9) Abstain  0%

Can upfront AI be switched to TAM after 2 yrs?

1)  Yes  75%  2)  No  22.5%  9) Abstain  2.5%

 

16. Endocrine Therapy:  Duration

              After 5 years of adjuvant Tam, continued AI, AI/OS or Tam to 10 years should be recommended to:

Ÿ   Premenopausal patients with node-positive disease?

Ÿ   1)  Yes  100%  2)  No  0%  9) Abstain  0%

Ÿ   Premenopausal patients with node-negative disease?

1)  Yes  15.4%  2)  No  4.4%  9) Abstain  10.3%

Ÿ   Premenopausal patients with grade 3 or high Ki-67?

1)  Yes  73.8%  2)  No  21.4%  9) Abstain  4.8%

Ÿ   Postmenopausal patients with node-positive disease?

1)  Yes  95.2%  2)  No  4.8%  9) Abstain  0%

Ÿ   Postmenopausal patients with node-negative disease?

1)  Yes  14.6%  2)  No  80.5%  9) Abstain  4.9%

Ÿ   Postmenopausal patients with grade 3 or high Ki-67?

1)  Yes  76.7%  2)  No  18.6%  9) Abstain  4.7%

Ÿ   Postmenopausal patients, premenopausal at baseline?

1)  Yes  66.7%  2)  No  25.6%  9) Abstain  7.7%

 

17. Endocrine Therapy:  Duration

              Provided an indication exists for therapy beyond the first 5 years:

              After 5 years of adjuvant therapy involving switch from Tam to an AI (therefore assuming postmenopausal status at the 5 year time point and reasonable tolerance to endocrine therapy), patients should be recommended to receive:

Ÿ   A further 5 years of tamoxifen

1)  Yes  39.4%  2)  No  57.6%  9) Abstain  3%

Ÿ   Continue AI to a cumulative total of 5 years AI

1)  Yes  75%  2)  No  22.5%  9) Abstain  2.5%

Ÿ   A further 5 years AI

1)  Yes  31.4%  2)  No  60%  9) Abstain  8.6%

Ÿ   No further endocrine therapy

1)  Yes  13.9%  2)  No  83.3%  9) Abstain  2.8%

After 5 years of straight AI adjuvant therapy, patients should be recommended to receive:

Ÿ   A further 3 to 5 years of tamoxifen

1)  Yes  34.1%  2)  No  63.4%  9) Abstain  2.4%

Ÿ   A further 3 to 5 years AI

1)  Yes  42.9%  2)  No  57.1%  9) Abstain  0%

Ÿ   No further endocrine therapy

1)  Yes  40.9%  2)  No  54.5%  9) Abstain  4.5%

             

中休み後

After 5 years of adjuvant therapy involving tamoxifen x 2 years followed by AI x 3 years (assuming postmenopausal status and tolerance of hormonal therapy), the preferred treatment is:

1)       Additional 5 years of tamoxifen                         3.2%

2)       Continue AI to a total of 5 years in total           54.8%

3)       Continue AI for 5 full years                               16.1%

4)       No further treatment                                       16.1%

9)       Abstain                                                            9.7%

 

After 5 years of straight AI therapy, my recommendation in a patient who remains at moderate risk of recurrence and is tolerating endocrine therapy is:

1)     3 – 5 years of tamoxifen                       27%

2)     3 – 5 years of AI                                 37.8%

3)     No further endocrine therapy                 29.7%

9)     Abstain                                                5.4%

 

The optimal duration of OFS in a premenopausal woman who has an indication to receive this treatment is:

1)     2 – 3 years                                              16.7%

2)     5 years                                                    56.7%

3)     Lifelong                                                  3.3%

9)     Abstain                                                   23.3%

 

18. Chemotherapy

              Factors which are relative indications for the inclusion of adjuvant cytotoxic chemotherapy include:

Ÿ   Histological grade 3 tumor

1)  Yes  97.4%  2)  No  2.6%  9) Abstain  0%

Ÿ   Any positive node

1)  Yes  38.7%  2)  No  61.3%  9) Abstain  0%

Ÿ   4 or more positive node

1)  Yes  95.1%  2)  No  4.9%  9) Abstain  0%

Ÿ   Ki-67 high

1)  Yes  75%  2)  No  8.3%  9) Abstain  16.7%

Ÿ   Age < 35

1)  Yes  41.7%  2)  No  58.3%  9) Abstain  0%

Ÿ   Extensive lymph-vascular invasion

1)  Yes  67.6%  2)  No  32.4%  9) Abstain  0%

Ÿ   Low hormone receptor staining

1)  Yes  81.1%  2)  No  18.9%  9) Abstain  0%

 

19. Chemotherapy:  Luminal A

              Is Luminal A phenotype less responsive to chemotherapy?

1)  Yes  88.1%  2)  No  4.8%  9) Abstain  7.1%

              Should chemotherapy be added for high risk (based on T-size)?

1)  Yes  36.4%  2)  No  63.6%  9) Abstain  0%

              If so, the minimum T-size to recommend chemotherapy is:

1.     1 cm                                                                     2.6%

2.     2 – 5 cm                                                               10.5%

3.     > 5 cm                                                                  23.7%

9.     Abstain (e.g. if you voted NO to the previous question)  63.2%

 

20. Chemotherapy:  Luminal A

              Should chemotherapy be added for high risk (based on LVI)?

1)  Yes  28.6%  2)  No  66.7%  9) Abstain  4.8%

              Should chemotherapy be added for high risk (based on 1 – 3 nodes involved)?

1)  Yes  34.9%  2)  No  65.1%  9) Abstain  0%

              Should chemotherapy be added for high risk (based on 4 or more nodes involved)?

1)  Yes  91.1%  2)  No  6.7%  9) Abstain  2.2%

 

21. Chemotherapy:  Luminal B (HER2 negative)

              In IHC Luminal B-like tumors chemotherapy should be recommended in:

Ÿ   All patients

1)  Yes  22%  2)  No  78%  9) Abstain  0%

Ÿ   Only in patients with other indications of increased risk

1)  Yes  87.5%  2)  No  7.5%  9) Abstain  5%

Chemotherapy may be omitted for patients with luminal B-like disease and:

Ÿ   Low Oncotype DX score

1)  Yes  94.9%  2)  No  0%  9) Abstain  5.1%

Ÿ   Intermediate Oncotype DX score

1)  Yes  36.4%  2)  No  43.2%  9) Abstain  20.5%

Ÿ   MammaPrint Low Risk

1)  Yes  72.1%  2)  No  16.3%  9) Abstain  11.6%

Ÿ   Low PAM50 ROR score

1)  Yes  82.5%  2)  No  7.5%  9) Abstain  10%

Ÿ   EndoPredict Low Risk

1)  Yes  69.6%  2)  No  10.9%  9) Abstain  17.4%

 

22. Chemotherapy:  Luminal B (HER2 negative)

              If given, should the regimen contain anthracylines?

1)      Yes  83.3%  2)  No  13.9%  9) Abstain  2.8%

If given, should the regimen contain taxanes?

1)      Yes  76.9%  2)  No  20.5%  9) Abstain  2.6%

Should chemotherapy ever comprise 6 cycles of the same therapy (e.g, 6 courses of FEC or AC)?

1)      Yes  21.6%  2)  No  75.7%  9) Abstain  2.7%

Is there a high risk group for which dose-dense therapy with G-CSF should be preferred?

1)      Yes  57.1%  2)  No  40%  9) Abstain  2.9%

 

23. Chemotherapy:  TNBC Ductal

              Should the regimen for TNBC phenotype contain anthracyclines and taxanes?

1)  Yes  92.3%  2)  No  2.6%  9) Abstain  5.1%

              Should a platinum based regimen be considered?

Ÿ   In all patients with TNBC?

1)  Yes  7.1%%  2)  No  92.9%  9) Abstain  0%

Ÿ   Only when known BRCA mutation?

1)      Yes  57.9%  2)  No  36.8%  9) Abstain  5.3%

Ÿ   In young age < 40 years with TNBC?

1)  Yes  75%  2)  No  25%  9) Abstain  0%

Ÿ   In patients < 60 years with TNBC

Ÿ   1)  Yes  77.8%  2)  No  11.1%  9) Abstain  11.1%

Ÿ    

              Should dose-dense ChT requiring growth factor support be preferred?

1)  Yes  45%  2)  No  52.5%  9) Abstain  2.5%

 

24. Chemotherapy:  HER2-positive Stage 2

              Should chemotherapy always be given to patients with stage 1 disease who require anti-HER2 therapy?

1)  Yes  97%  2)  No  3%  9) Abstain  0%

              Should the chemotherapy regimen for these patients preferably contain anthracyclines?

1)  Yes  88.9%  2)  No  7.4%  9) Abstain  3.7%

              Should the chemotherapy regimen for these patients contain taxanes?

1)  Yes  97.2%  2)  No  2.8%  9) Abstain  0%

              Should anti-HER2 therapy start concurrent with taxane?

1)  Yes  97.3%  2)  No  2.7%  9) Abstain  0%

 

25. Chemotherapy:  HER2-positive

              Assuming HER2 positivity is determined according to ASCO/CAP guidelines:

l  Do the large majority of patients with HER2 positive stage 1 disease require anti-HER2 therapy:

Ø  with T1a disease?

1)  Yes  20.7%  2)  No  79.3%  9) Abstain  0%

Ø  with T1b disease?

1)  Yes  81.4%  2)  No  18.6%  9) Abstain  0%

Ø  with T1c disease?

1)  Yes  100%  2)  No  0%  9) Abstain  0%

l  If given, should the chemotherapy regimen for these patients contain anthracyclines?

1)  Yes  57.9%  2)  No  42.1%  9) Abstain  0%

l  If given, is the combination of paclitaxel and trastuzumab a reasonable option?

1)      Yes  86.5%  2)  No  2.7%  9) Abstain  10.8%

 

l  Stage 1, HER2 positive, T-size < 1cm

1)       Anthracyclines Taxane + Trastuzumab       27%

2)       Palictaxel + Trastuzumab                                   64.9%

3)       Something else                                                     8.1%

9)       Abstain                                                                 0

 

26. Anti-HER2 Therapy – Which Agents?

              (These questions assume the availability of the relevant agents)

              In patients requiring anti-HER2 therapy in the postoperative adjuvant setting for a T2 tumor with 4 involved nodes: Therapy should include both trastuzumab and pertuzumab

1)  Yes  50%  2)  No  37.5%  9) Abstain  9.4%

?

 

27. Neo-Adjuvant Systemic Therapy

              (possibly followed by additional adjuvant chemo)

              Stage II HER2-positive Disease

    If given, in HER2-positive tumors, acceptable regimen should include:

Ÿ   Taxane + trastuzumab only

1)      Yes  18.8%  2)  No  75%  9) Abstain  6.3%

Ÿ    

1)  7.7%  2)  23.1%  3)  12.8%  4)  0  5) Abstain  56.4%

Ÿ   Taxane + trastuzumab only

2)      Yes  46.7%  2)  No  46.7%  9) Abstain  6.7%

Ÿ   Taxane, trastuzumab and pertuzumab

1)  Yes  73.1%  2)  No  19.2%  9) Abstain  7.7%

Ÿ   Platin, taxane, trastuzumab ±pertuzumab

1)  Yes  39.3%  2)  No  53.6%  9) Abstain  3.6%

Ÿ   Non-taxane regimen containing platin, trastuzumab±pertuzumab

1)  Yes  2.9%  2)  No  91.2%  9) Abstain  5.9%

Ÿ   Anthracycline -> taxane and anti-HER2

1)  Yes  97.2%  2)  No  2.8%  9) Abstain  0%

 

28. Neo-Adjuvant Systemic Therapy

              Stage II Triple-Negative Disease

    If given, in patients with triple-negative tumors, the preferred regimen should include:

Ÿ   High-dose alkylating agent

1)      Yes  17.2%  2)  No  79.3%  9) Abstain  3.4%

Ÿ   Platin

1)      Yes  25%  2)  No  75%  9) Abstain  0%

Ÿ   Anthracycline -> taxane

1)      Yes  94.7%  2)  No  2.6%  9) Abstain  2.6%

Ÿ   Nab-paclitaxel -> EC

1)  Yes  22.9%  2)  No  71.4%  9) Abstain  5.7%

Ÿ   Anthracycline -> regimen with alkylating agents (e.g. classic CMF)

1)  Yes  25.7%  2)  No  65.7%  9) Abstain  8.6%

 

29. Neo-Adjuvant Systemic Therapy:

              Chemotherapy in Luminal Disease

    Neoadjuvant cytotoxic therapy should be discussed as an option in patients with ‘Luminal A-like’ tumors:

1.       In the majority of cases                                                      2.9%

2.       Only if conservative surgery would not otherwise be feasible    73.5%

3.       Never                                                                             20.6%

9.       Abstain                                                                             2.9%

    …and in patients with ‘Luminal B-like’ tumors (HER2 neg.)

1.       In the majority of cases                                                     37.8%

2.       Only if conservative surgery would not otherwise be feasible    45.9%

3.       Only if biological features predict high chance of pCR              16.2%

4.       Never                                                                               0

9.       Abstain                                                                             0

 

30. Neo-Adjuvant Endocrine Therapy

              Is neoadjuvant endocrine therapy without cytotoxics a reasonable option for postmenopausal patients with endocrine responsive disease?

1)  Yes  87.9%  2)  No  12.1%  9) Abstain  0%

              If yes, for which duration?

1.     1 – 2 weeks “window” prior to surgery               7.1%

2.     3 – 4 months                                                 3.6%

3.     4 – 8 months                                                42.9%

4.     Until maximal response                                   42.9%

9.     Abstain                                                         3.6%

 

    Is neoadjuvant endocrine therapy without cytotoxics a reasonable option for postmenopausal patients with endocrine responsive disease?

1.     In the majority of cases                                                      2.9%

2.     Only if conservative surgery would not otherwise be feasible     73.5%

3.     Never                                                                             20.6%

9.     Abstain                                                                            2.9%

 

31. Neo-Adjuvant Systemic Therapy

              Chemotherapy in Luminal Disease

    Neoadjuvant cytotoxic therapy should be discussed as an option in patients with ‘Luminal A-like’ tumors: …and in patients with ‘Luminal B-like’ tumors (HER2 neg.)

1)      Yes  16%  2)  No  60%  9)  Abstain  4%

 

1.     In the majority of cases                                                     37.8%

2.     Only if conservative surgery would not otherwise be feasible     45.9%

3.     Only if biological features predict high chance of pCR               16.2%

4.     Never                                                                                0

9.     Abstain                                                                              0

    Neoadjuvant cytotoxic therapy should be discussed as an option in patients with ‘Luminal A-like’ tumors:

1.     In the majority of cases                                                      5.1%

2.     Only if conservative surgery would not otherwise be feasible     71.8%

3.     Never                                                                              23.1%

9.     Abstain                                                                               0

 

32. Bisphosphonates

    Is bisphosphonate treatment, such as zoledronic acid q 6 months or oral clodronate, during adjuvant endocrine therapy indicated to improve DFS?

Ÿ   In premenopausal patients receiving LHRH plus TAM?

1)  Yes  43.6%  2)  No  56.4%  9) Abstain  0%

Ÿ   In premenopausal patients not receiving LHRH?

1)  Yes  5.3%  2)  No  94.7%  9) Abstain  0%

Ÿ   In postmenopausal patients?

1)  Yes  58.3%  2)  No  41.7%  9) Abstain  0%

 

Should adjuvant denosumab substitute for bisphosphonate?

1)  Yes  3.7%  2)  No  88.9%  9) Abstain  7.4%

 

33. Elderly Patients

    In the absence of significant co-morbidity the maximum age at which a standard chemotherapy regimen should be advised is:

1.     55 yrs                          2.6%

2.     65 yrs                          0

3.     70 yrs                          2.6%

4.     75 yrs                          0

5.     80 yrs                          7.7%

6.     There is no absolute age limit. Rather, it depends on the disease, the presence of co-morbidity, the life expectancy, and the patient’s preferences

87.2%

9.     Abstain                       0

 

34. Elderly Patients: Radiation

    In postmenopausal patients with ER-positive tumors receiving endocrine therapy, radiation after breast conserving surgery can be omitted in patients aged over:

1.     55 yrs                          0%

2.     65 yrs                          5.6%

3.     70 yrs                          27.8%

4.     75 yrs                          8.3%

5.     80 yrs                          0

6.     There is no age at which radiation should be omitted

55.6%

10.  Abstain                       2.8%

 

35. Young Patients  (Age < 40)

Testing for BRCA 1 and 2 mutations is indicated

1)      Yes  73.5%  2)  No  23.5%  9) Abstain  0%

    Testing for BRCA 1 and 2 mutations is indicated for TNBC  (?)

1)  Yes  90.9%  2)  No  6.1%  9) Abstain  3%

    (?)

1)    7.7%    2)   23.1%    3)  12.8%  4)  0  5)   56.4%

    (?)

1)    48.5%   2)    48.5%    9)   3%

 

Testing for high risk mutations in other genes (e.g. PALB2) is indicated

1)  Yes  41.2%  2)  No  50%  9) Abstain  8.8%

Fertility preservation (e.g. by ovarian tissue or oocyte conservation) should be offered

1)  Yes  87.5%  2)  No  10%  9) Abstain  2.5%

Ovarian function suppression during chemotherapy for receptor-negative disease should be offered

1)  Yes  78.9%  2)  No  18.4%  9) Abstain  2.6%

 

36. High Risk Mutations

    Testing for high risk mutations is indicated in:

Ÿ   All women with breast cancer

1)  Yes  11.1%  2)  No  88.9%  9) Abstain  0%

Ÿ   Patients with a strong family history

1)  Yes  94.3%  2)  No  5.7%  9) Abstain  0%

Ÿ   Patients under 35 at diagnosis

1)  Yes  88.9%  2)  No  7.4%  9) Abstain  3.7%

Ÿ   Patients under 50 at diagnosis

1)  Yes  7.4%  2)  No  92.6%  9) Abstain  0%

Ÿ   Patients under 50 with ER and HER negative tumors

1)  Yes  70%  2)  No  30%  9) Abstain  0%

Ÿ   Patients with ER and HER2 negative tumors

1)  Yes  25.7%  2)  No  71.4%  9) Abstain  2.9%

Ÿ   Patients with a basal-like tumor

1)  Yes  48.6%  2)  No  45.7%  9) Abstain  5.7%

Discovery of a BRCA 1 or 2 mutation influences treatment of the tumor

1)      Yes  77.8%  2)  No  22.2%  9) Abstain  0%

Discovery of a BRCA 1 or 2 mutation influences treatment of the tumor (adjuvant)

1)  Yes  28.9%  2)  No  65.8%  9) Abstain  5.3%

 

37. Breast Cancer Diagnosed During Pregnancy

l  Premature delivery should be avoided if possible

1)  Yes  88.9%  2)  No  3.7%  9) Abstain  7.4%

l  Breast conservation is a suitable option

1)  Yes  89.5%  2)  No  2.6%  9) Abstain  7.9%

l  Lymphoscintigraphy and SNB are safe

1)  Yes  64.5%  2)  No  29%  9) Abstain  6.5%

l  Immediate post-mastectomy reconstruction is an appropriate option

1)  Yes  52.6%  2)  No  36.8%  9) Abstain  10.5%

l  If indicated, anti-HER2 therapy should be delayed until after delivery

1)  Yes  87.2%  2)  No  7.7%  9) Abstain  5.1%

 

38. Pregnancy After Breast Cancer

    Is it reasonable to interrupt endocrine therapy to allow attempted pregnancy:

l  At any time during endocrine therapy?

1)  Yes  26.3%  2)  No  68.4%  9) Abstain  5.3%

l  After 18 – 30 months endocrine therapy?

1)  Yes  60.6%  2)  No  30.3%  9) Abstain  9.1%

l  Only in absence of high risk factors?

1)      Yes  61.1%  2)  No  27.8%  9) Abstain  11.1%

 

Post-manopausal, T2, ER positive, HER2 negative tumor?

1)  endocrine therapy  83.8%  2)  chemotherapy  16.2%  9) Abstain  0%

 

39. Male Breast Cancer

    Most breast cancers in males are endocrine responsive. Tamoxifen is currently advised. Adjuvant therapy options beyond tamoxifen include:

l  Aromatase inhibitors alone

1)  Yes  29%  2)  No  58.1%  9) Abstain  12.9%

l  Aromatase inhibitors + LHRN a

1)  Yes  29.6%  2)  No  66.7%  9) Abstain  3.7%

l  Complete estrogen blockade

AR?

 

40. Diet and Exercise

l  Should patients receive specific dietary advice?

1)  Yes  40%  2)  No  57.5%  9) Abstain  2.5%

l  Should patients with vitamin D deficiency receive vitamin D supplement?

1)  Yes  57.1%  2)  No  34.3%  9) Abstain  8.6%

l  Should an exercise regimen be part of standard care?

1)  Yes  76.7%  2)  No  23.3%  9) Abstain  0%

l  Should weight loss / avoidance of weight gain be recommended?

1)  Yes  87.5%  2)  No  7.5%  9) Abstain  5%