A. N. DIBA

GLOBAL-BIOMED

Breast

Cancer

And

Advises

of

German

Gynoco

logical

Oncology

23 Nov 2020

The July 2018 issue of the journal KARGER "karger.com" (2018, Vol.13, No. 3) printed the recommendations for the sake of the breast cancer.

These recommendations for the sake of the breast cancer were from German Gynecological Oncology Group/AGO).

The authors of these recommendations who sent it to be published in the journal KARGER entitled it:

"AGO Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2018".

Authored by Prof. Dr. Cornelia Liedtke,Klinik für Gynäkologie mit Brustzentrum BB (Charité - Universitätsmedizin Berlin/Campus Mitte, Berlin, Germany) and her co-aurhors Jackisch C. · Thill M. · Thomssen C. · Müller V. · Janni W.

Cornelia Liedtke and other co-authors who authored these AGO Recommendations to be published in the journal KARGER they acted on behalf of the AGO Breast Committee.

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The introduction of these AGO Recommendations begins with:

"For almost 20 years, the Breast Committee of the Arbeitsgemeinschaft Gynäkologische Onkologie (German Gynecological Oncology Group/AGO) has been preparing and updating evidence-based recommendations for the diagnosis and treatment of patients with early and metastatic breast cancer."

The authors address, "The AGO Breast Committee consists of gynecological oncologists specialized in breast cancer and interdisciplinary members specialized in pathology, radiological diagnostics, medical oncology, and radiation oncology."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The writers of the AGO recommensations in one part of their publucation in the journal of KARGER talk about the prognostic and predictive factors and say these factors are an essential part of therapy concepts in early and advanced breast cancer.

They explain:

" In HR-positive HER2-negative early breast cancer with 0-3 involved lymph nodes, gene expression assays may be used if established clinical pathological factors do not allow therapy decisions regarding the use of chemotherapy in addition to the standard of endocrine therapy."

"Patients with an estimated risk of recurrence of more than 10% at 10 years are generally considered candidates for upfront or adjuvant chemotherapy."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The authors refer to the results from other study and hence they address:

"In triple-negative early breast cancer, the germline BRCA status is predictive in response to NACT."

The authors add:

"In the neoadjuvant GeparQuinto trial, in 74 (15.8%) out of 469 TNBC patients with available germline DNA, BRCA1 (n = 61) or BRCA2 (n = 13) mutations were detected. pCR (ypT0/ypN0) was observed in 50% (n = 37) of the mutation carriers, but in only 31.1% (n = 123) of the patients without mutations (p = 0.002)."

The writers add:

"In HER2-positive early breast cancer, a meta-analysis (n = 967) demonstrates that pathological complete response (pCR) after neoadjuvant therapy (chemotherapy + anti-HER2 therapy) is significantly lower in phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA)-mutant versus wild-type tumors (16.2% vs. 29.6%; p < 0.001) (LoE IB).

"This difference was mostly due to a substantial difference in HR-positive tumors with pCR rates of 7.6% versus 24.2% (p smaller than 0.001); in HR-negative tumors, the numerical difference was not significant (27.2 vs. 36.4%; p = 0.125) [84]."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The authors write:

"As there are evidence-based consequences for patient management beyond the neoadjuvant therapy, germline BRCA determination is recommended in TNBC (LoE IIB AGO+)."

The writers add, "Yet, as shown earlier in the GeparSixto trial, the use of platinum should not depend on the germline BRCA status."

The authors of the AGO Recommendstions address about the breast cancer surgery under oncological aspects and write the following:

"The extent of breast surgery has been consistently reduced in recent years."

"No ink on tumor is the accepted standard for resection margins for patients who undergo primary surgery or surgery after NACT (provided that all suspicious lesions according to preoperative imaging are resected (LoE 2a/A/AGO++ and LoE 2b/B/AGO++, respectively)).

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The authors of German AGO Recmendation go on to address:

"For patients who present initially with (histologically proven) positive axillary lymph nodes (pN+), the feasibility and accuracy of SLNB is lower than in the adjuvant setting (SENTINA, ACOSOG 1071, GANEA I) [87-89]."

The writers add:

"Data on long-term outcome are insufficient, and it is unclear if the unfavorable FNRs translate into higher rates of recurrences."

"Therefore," explain the authors, "the AGO still cannot generally recommend SLNB as standard procedure in clinically negative axillae after NACT (ycN0) in cases among whom tumor-infiltrated lymph nodes (cN+/pN+) have histologically been proven before NACT (LoE 2bB/AGO+/-)."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The authors address:

"For HER2-positive patients, HER2-directed therapy is standard as part of neoadjuvant therapy."

The writers add:

"Given the significant increase in pCR rates and the trend for improved PFS observed in the neoadjuvant NeoSphere trial with the addition of pertuzumab to trastuzumab, dual blockade is highly recommended in patients at high risk for recurrence [108-111] (LoE 2b/B/AGO++)."

The authors address:

"Three studies presented at the last San Antonio Breast Cancer Symposium were negative for the overall groups (DATA, IDEAL, and National Surgical Adjuvant Breast and Bowel Project (NSABP) B-42)."

They explain:

"However since subgroups can possibly benefit, extension of endocrine therapy with an AI should be offered after initial AI-containing therapy inpatients who are at higher risk and have so far tolerated the AI well - e.g., those with good bone health, younger age, high risk according to immunohistochemical characteristics, and positive nodal status (LoE 1b/GR B/AGO+)."

"However, there is as yet no evidence of a significant effect on OS."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

Adjuvant Cytotoxic
and Targeted Therapy

According to these AG Recommendations:

"If adjuvant chemotherapy is indicated, neoadjuvant therapy should always be considered (AGO++)."

"In adjuvant therapy, systemic treatment encompassing 6 cycles of FEC (5-fluorouracil, epirubicin, cyclophosphamide) is no longer recommended."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

About the adjuvant therapy the writers of these AG recommendations refer to the result of other study [138] and they write:

"Standard adjuvant chemotherapy consists of combination regimens based on anthracyclines and taxanes in patients with HER2-negative tmumors (LoE 1a/A/AGO++)."

The authors continue to cite from the result of other investigation [138] and hence they address the following:

"Recommended conventional regimens include 4 × EC/AC (epirubicin, cyclophosphamide or doxorubicin, cyclophosphamide), followed by 12 × paclitaxel (weekly, q7d) (LoE 2b/B/AGO++)."

"The benefit of this regimen has recently been confirmed in the 10-year follow-up data from E1199."[138].

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

Complementary Therapy

- Survivorship

About the complementary therapy in the breast cancer, the authors of the AG Recommendations cite another study [177] and hence they address the following points:

"Integrative oncology is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments."

The writers point out:

"Integrative oncology aims to optiddmize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment" [177].

The authors address:

"In 2018, the AGO guidelines for ‘Complementary Therapy - Hormonal Treatment and Alternatives in Breast Cancer Survivors - Survivorship' did not change substantially, since the data presented in 2017 altered mostly evidence levels (LoE) but not the AGO recommendations."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The writers talk about the inflammatory breast cancer (IBC) and address:

"In inflammatory breast cancer (IBC), mastectomy is standard of care (AGO+)."

They refer to another work [189] and hence they note:

"In a large IBC cohort from the Surveillance, Epidemiology and End Results (SEER) data base (n = 3,374), no statistically significant difference regarding breast cancer-specific survival or OS was found between the different types of breast surgery such as breast-conserving surgery, contralateral prophylactic mastectomy, breast reconstruction, or standard unilateral mastectomy [189]."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

The axillary metastases of
occult breast cancer
(axillary CUP)

The authors of AG Recmendations refer to the results of a study [190] in conjunction with the axillary metastases of occult breast cancer (axillary CUP), and hence they address:

"In axillary metastases of occult breast cancer (axillary CUP), radiotherapy of the ipsilateral breast improves outcome (AGO+)."

According to the results of that study [190] the authors of AG Recommendations write:

"In a large case series from the National Cancer Database, axillary metastases with an occult breast cancer were very rare (0.09%)."

"Treatment with radiotherapy and AD was an independent predictor of OS in multivariable analysis (HR 0.509, 95% CI 0.321-0.808, p = 0.004) [190]."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

Citing another study [191], the authors write the following:

"Metaplastic breast cancer is a rare subtype with an incidence of 0.2-5% of all breast cancers [191].

The writers refer to another study [192] add:

"These tumors are characterized by an epithelial and mesenchymal differentiation with 2-3 different components and a high proliferation rate."

"These different components are the basis for the classification according to the World Health Organization (WHO) criteria [192]."

According to them with the references to the studies [193 and 194]:

" More than 90% of metaplastic breast cancers are negative for ER, PR, and HER2 but, in contrast, there is an overexpression of HER1 and cytokeratin 5/6 (CK5/6) (stem cell and BRCA-like) [193] and the molecular profile is more basal-like [194]."

Source:

AGO
Recommen-
dations
for
the
Diagnosis
and
Treatment
of
Patients
with
Early
Breast
Cancer:
Update
2018"

Conclusion

The authors conclude their recommendations and address the following:

" These guidelines offer the freshest recommendations in the diagnosis and treatment of early breast cancer."

"Meanwhile, we have reached a rather high level with regard to long-term prognosis, exhibiting low rates of recurrences and deaths even after 10 and 15 years."

The

writers of these guudelines note:

"The trend of these recommendations shows increasing optimization and individualization by reducing treatment aggressiveness if possible (e.g. less axillary surgery, hypofractionation of radiotherapy in BCT) and escalating some specific therapies modalities (e.g. irradiation of lymph node areas, dose-dense chemotherapy)."

"Thus, following these concepts, early breast cancer is a curable disease. Having accepted some toxicity, we have to put our efforts into the reduction of side effects now."

23 March
2021:
Walter Isaccson:
"Social
Inequalities
& Gene-
editing"

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2018

San Antonio

Breast Cancer

Symposium

23 Nov 2020

On December 8, 2028, the website E CANCER "ecancer.org" reported about a meeting of the breast cancer experts in San Antonio.

The breast cancer experts in this meeting discussed about the "Role of chemotherapy in the treatment of metastatic breast cancer patients".

According to this report:

This gathering of the breast cancer experts was called as the San Antonio Breast Cancer Symposium (SABCS 2018) annual meeting.

The goal of this symposium was an educational breast cancer panel discussion.

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients

The website addresses:

"Professors Joseph Gligorov, Yen-Shen Lu, Chris Twelves and Dr Reshma Mahtani meet in San Antonio at the San Antonio Breast Cancer Symposium 2018 annual meeting.

The report says:

"Their talk covers the role of chemotherapy in the treatment of metastatic breast cancer patients."

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients

The website "ecancer.org" adds:

"Professor Gligorov chairs the discussion, opening by asking Dr Mahtani to comment on recent data surrounding novel chemotherapy combinations used to treat metastatic breast cancer patients, in particular in the triple-negative population."

The information in the report addresses:

"Here Dr Mahtani discusses the combination of eribulin with gemcitabine referencing the data seen at SABCS."

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients

According to "ecancer.org":

"Prof Twelves then comments on eribulin’s efficacy as a single agent, and the group discuss the use of eribulin as a backbone regimen in the treatment of mBC patients."

The report in the website "ecancer.org" continues:

"The panel then discuss the importance of individualising dosage in breast cancer patients, and the need for precision medicine and personalised chemotherapy, here referencing BRCA status, SNPs and treating patients with disease recurrence."

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients

The website's report addresses:

"The discussion then moves to Prof Lu who comments on the combination of chemotherapy with anti HER2 regimens, and Prof Twelves discusses the phase II and real-world equivalent data."

According to this report:

"Prof Gligorov then asks Prof Twelves to comment on the combination of chemotherapy with antiangiogenic agents."

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients

The information in the report says:

"Here the panel discuss the use of 2nd line eribulin in combination with bevacizumab following taxane treatment, and the efficacy and toxicity profile of the drug in this setting."

Finally the report addresses:

"The discussion is summarised by speaking through the role of chemotherapy in the treatment pathway of mBC patients, and the importance of understanding both the safety and efficacy of the chemotherapeutic agent used alongside the individual needs of the patient."

Source:

Role
of
chemo
therapy
in
the
treatment
of
metastatic
breast
cancer
patients