Advanced breast cancer (ABC) is a treatable but still generally incurable disease. The goals of care are to optimise both length and quality of life.1,2 Due to continuous research, several advances have been made, particularly for the human epidermal growth factor receptor 2 (HER-2)-positive and for luminal-like subtypes. Notwithstanding these advances, median overall survival of patients with ABC is still only 2–3 years, although the range is wide1,2 and survival may be longer for patients treated in specialised institutions.1,2 Implementation of current knowledge is highly variable among countries and within each country.


The first international consensus guidelines on locally advanced and metastatic breast cancer have been published in Annals of Oncology and The Breast.1,2 They are a collaborative effort between the European Society for Medical Oncology (ESMO) and the European School of Oncology (ESO).

Previous consensus guidelines on advanced breast cancer were published in 2011 and focused on metastatic breast cancer.3 The 2014 document also now provides recommendations on local and regional advanced breast cancer without metastases for the first time.
Professor Nadia Harbeck, co-author of the paper and also of the previous ESMO Clinical Practice Guidelines on Locally Recurrent and Metastatic Breast Cancer and head of the Breast Centre, University of Munich, Germany, said: “Local and regional advanced breast cancer without metastases is an intermediate clinical diagnosis between early stage breast cancer and metastasised breast cancer. There is little data in this area and a lot of individualised therapy concepts. In the paper we summarise the evidence and provide recommendations to give these patients the best possible medical care.”


The guidance includes a definition for endocrine resistance, a term used for patients who do not respond well to endocrine therapy, and visceral crisis, a situation in which patients have advanced life threatening liver disease and chemotherapy. Harbeck said: “Standard international terminology is needed so that findings from clinical trials on new therapies can be applied to clearly defined clinically relevant patient populations. Until now different terms have been used making it difficult to apply drug approvals given for one study population to patients in clinical practice.”

Novel recommendations are provided for specific metastatic sites including pleural effusions, liver metastases and chest wall recurrences. There are also updates that incorporate new evidence on everolimus in hormone receptor positive disease, and the new anti-HER2 drugs pertuzumab and trastuzumab emtansine.

Commenting on the impact of the ESO-ESMO guidelines, Harbeck said: “This document will help oncologists around the world improve their practice and the care they provide to patients with advanced breast cancer because the recommendations were agreed upon by an international group of clinicians from different specialties like radiotherapy, radiology, pathology, gynaecology and medical oncology as well as patient advocates.”

The age of the patient is also mentioned in the guidance. It states that although age is an important factor to consider in decision-making for ABC, it must not be the sole factor to determine the intensity and type of treatment. There is a tendency to withhold therapy in some elderly patients because of fear of toxicity or concern about comorbidity. In some cases, however, such therapies may be highly effective and could improve both survival and quality of life. At the same time, younger patients are often overtreated or treated somewhat inappropriately. Age may influence breast cancer treatment, but it should not be the guiding force.1,2

Survivorship was also addressed in the guidance. The complex needs of patients living with ABC, at times for many years, as well as their caregivers, should be addressed not only in terms of supportive and palliative care but also regarding ‘survivorship’ concerns. The multidisciplinary approach of ABC should encompass early in the history of the disease not only physical, but also functional, social, psychological, and spiritual, domains.1,2

It also stated that it is important to clearly define the disease context with patients and families, addressing the concept of uncertainty and tailoring the treatment strategy according to individual priorities and disease status.1,2 Specific psychosocial needs of young and elderly patients should also be recognised and supported.

The guideline panel also said much more research is needed to answer questions about four situations:
• Breast cancer that has spread to the liver, chest cavity just outside the lungs, or skin
• HER2-positive breast cancer that comes back during or after Herceptin treatment
• Surgery to remove the primary cancer in people with metastatic disease at diagnosis
• The role of aromatase inhibitors in treating advanced-stage male breast cancer.

In their conclusion, the authors said that the complexity of this disease, the multiple factors that must be taken into account, the lack of high-level evidence for several clinical situations, and new highly specialised techniques available for local management of specific sites of metastases, all constitute strong reasons for the treatment of these patients by a specialised multidisciplinary team, rather than management by an isolated oncologist regardless of his/her skills or experience.

References

1. Cardoso F, et al. ESO-ESMO 2nd international consensus guidelines for advanced breast cancer (ABC2) Ann Oncol 2014; 25 (10): 1871–88
2. Cardoso F, et al. ESO-ESMO 2nd international consensus guidelines for advanced breast cancer (ABC20. The Breast 2014; 23(5): 489–502
3. Cardoso F, Costa A, Norton L et al. 1st International consensus guidelines for advanced breast cancer (ABC1). The Breast. 2012; 21(3): 242–52