Value-Based Cancer Care Issues


March 2013, Highlights

Gabriel N. Hortobagyi, MD, Delivers the William I. McGuire Memorial Lecture

Caroline Helwick

Chemotherapy

The honor of delivering the William I. McGuire Memorial Lecture at this year’s meeting went to Gabriel N. Hortobagyi, MD, FACP, Professor of Breast Medical Oncology and Nellie B. Connally Chair in Breast Cancer at the University of Texas M.D. Anderson Cancer Center, Houston. Dr McGuire cofounded the San Antonio Breast Cancer Symposium in 1977.

Neoadjuvant Systemic Therapy: Promising Experimental Model or Improved Standard of Care?

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Gene-Based Test Identifies Breast Cancer with Low Risk for Late Metastasis

Charles Bankhead

Prognostic Tests

An 8-gene panel has demonstrated potential for identifying patients with estrogen receptor (ER)-positive and HER2-negative breast cancer at low risk for late metastasis. Patients classified as low risk by the EndoPredict panel had a significantly lower rate of distant metastasis after 5 and 10 years of follow-up compared with patients who did not meet the test’s criteria for low risk, according to Peter Dubsky, MD, of the Breast Health Center, Associate Professor of Sur­gery, Medical University of Vienna, Austria.

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Targetable Pathways Revealed for Triple-Negative Breast Cancer

Audrey Andrews

Breast Cancer

The molecular make-up of triple- negative breast cancer is becoming better understood, and new evidence suggests that the main biologic pathways can be targeted with drugs, according to Justin Balko, PharmD, PhD, Postdoctoral Research Fellow and Researcher, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville. In his study on genetic alterations, 90% of the patients had mutations in 5 well-recognized pathways, and drugs developed to target these markers.

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Dose-Dense Chemotherapy in Breast Cancer

Audrey Andrews

Chemotherapy

Two studies presented in San Antonio reached conflicting conclusions regarding the value of dose-dense chemotherapy in patients with early breast cancer.

The phase 3 UK TACT2 trial compared standard chemotherapy with epirubicin plus CMF (cyclophosphamide/methotrexate/fluorouracil) with accelerated (dose-dense) epirubicin in node-positive or in high-risk, node-negative early breast cancer. The current report focused on the impact of accelerating epirubicin chemotherapy; the capecitabine/CMF comparison is premature.

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Adjuvant Chemotherapy Reduces Local and Regional Tumor Recurrence, Especially for Patients with ER-Negative Breast Cancer

Susan Reckling

Chemotherapy

Adjuvant chemotherapy should be recommended for patients with completely resected, isolated local or regional recurrence (ILRR) of breast cancer, and the argument is strongest for women with estrogen receptor (ER)-positive tumor recurrences, according to the results of the international Chemotherapy as Adjuvant for Locally Recurrent Breast Cancer (CALOR) trial.

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Risk of Leukemia after Chemotherapy Small, but Real

Audrey Andrews

Chemotherapy

Fewer than 0.5% of patients with breast cancer develop leukemia associated with chemotherapy, but this is 60% higher than the proportion documented in a previous analysis, according to a report based on the National Comprehensive Cancer Network (NCCN) database.

“Adjuvant chemotherapy was associated with a cumulative 10-year incidence of leukemia of about 0.5%, which appears to be higher than previously reported,” said Antonio Wolff, MD, Professor of Oncology at the Sidney Kimmel Comprehensive Can­cer Center, Johns Hopkins Medicine, Baltimore, MD.

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Intraoperative Radiotherapy Fares Well Against EBRT

Charles Bankhead

Radiation Therapy

Low-dose intraoperative radiation therapy has proved comparable with whole-breast irradiation for preventing breast cancer recurrence, according to the preliminary results of the large randomized Targeted Intraoperative Radiotherapy (TARGIT-A) trial.

After a median follow-up of 29 months, the estimated 5-year absolute difference in relapses is 2.0% in favor of whole-breast irradiation. Although this numerically favors whole-breast irradiation, the difference is still within the 2.5% margin established for noninferiority.

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Hypofractionation Validated for Breast Radiotherapy: Less Potential for Toxicity Shown

Charles Bankhead

Radiation Therapy

Ten-year disease control in patients with nonmetastatic breast cancer did not differ significantly between patients treated with a reduced-dose hypofractionated radiation therapy compared with a standard protocol, according to a study presented at the meeting.

The 10-year locoregional recurrence rate was 4.3% in patients who received a 40-Gy radiation dose in 15 fractions and 5.5% in patients randomized to 50 Gy in 25 fractions.

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HER2 Status Determined by Central Laboratory Testing May Be More Reliable than Routine Local Testing

Susan Reckling

Breast Cancer

Determining HER2 status utilizing novel central laboratory testing techniques has been shown to be more reliable than routine local HER2 testing, such as immunohistochemistry or in situ hybridization. This finding for patients with HER2-positive breast cancer may lead to future therapeutic applications for patients with HER2-negative breast cancer as well.

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One Year of Trastuzumab Remains the Standard of Care

Caroline Helwick

Breast Cancer

For patients with HER2-positive early breast cancer, 1 year of treatment with trastuzumab (Herceptin) remains the standard of care, according to the HERA trial and a subanalysis of the PHARE study.

The optimal duration of anti-HER2 adjuvant therapy has never been clearly established, and the issue continues to be studied in current trials, but for now, 1 year is the recommended treatment.

HERA: Trastuzumab Shows Robust Effect at 8 Years


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HER2 Mutations May Become New Treatment Targets

Caroline Helwick

Breast Cancer

Some patients who test HER2 negative by conventional tests may still benefit from anti-HER2 agents. This is the conclusion of a study that examined HER2 mutations in detail which was presented by Ron Bose, MD, PhD, Assistant Professor, Oncology Division, Department of Medicine, Washington University School of Medicine in St Louis, MO.

In a genetic analysis of 1500 women, 25 had HER2 mutations in the absence of gene amplification, which is the hallmark of HER2-positive breast cancer, Dr Bose reported.

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Molecular Profiling in Early Invasive Breast Cancer

Caroline Helwick

Prognostic Tests

In making decisions about adjuvant chemotherapy, biologic subtype has replaced nodal status and tumor size as parameters to consider, although subtype—and tests that define them—are still insufficient for the provision of optimal care, said Antonio C. Wolff, MD, Professor of Oncology at Johns Hopkins University School of Medicine, Baltimore. Dr Wolff spoke at an educational session devoted to molecular profiling.

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Sentinel Node Surgery Correctly Stages Lymph Nodes Following Neoadjuvant Chemotherapy

Audrey Andrews

Sentinel Node Management

Axillary lymph node dissection (ALND) may not be necessary after neoadjuvant chemotherapy in most patients, according to investigators who found that sentinel lymph node (SLN) dissection correctly staged more than 90% of patients.

A study of the American College of Surgeons Oncology Group, ACOSOG Z1071, evaluated whether SLN surgery may sufficiently substitute for ALND as a less invasive procedure.

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Letrozole Superior to Tamoxifen for a Subtype of Breast Cancer

Audrey Andrews

Hormone Therapy

A comparison of letrozole (Fem­ara) with tamoxifen (Nolva­dex) demonstrated that the former may be superior for the treatment of postmenopausal estrogen receptor (ER)-positive patients who have lobular carcinoma, according to a subanalysis of patients in the phase 3 BIG 1-98 trial. This subanalysis further showed that for the 2 histologic subtypes of breast cancer, luminal B tumors were more responsive to treatment than luminal A tumors.

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Evidence Still Cloudy for Anticancer Effects with Metformin

Caroline Helwick

Clinical Research

Observational studies have sug­gested that the antidiabetes agent metformin (Glucophage) may have anticancer effects. New studies have attempted to confirm this, but the results and their meaning still remain unclear.

Reviewing several studies presented at the meeting, Michael N. Pollak, MD, the Alexander Goldfarb Research Chair in Cancer Research and the Di­rec­tor, Division of Cancer Prevention, De­partment of Oncology, McGill Uni­versity, Montreal, Canada, said that there are many unanswered questions, but that “some of those questions have become clearer.”
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New Meta-Analysis: Complete Response to Neoadjuvant Therapy in Breast Cancer Predictor of Long-Term Benefit

Audrey Andrews

Clinical Research

A new meta-analysis confirmed that patients with breast cancer who achieve a pathologic complete response (pCR) to neoadjuvant therapy have a more favorable outcome than those who do not.

Patients who achieved a pCR had a 52% reduction in the probability of an event and a 64% reduction in the probability of death (P <.001 for both), as was shown in the meta-analysis of the Collaborative Trials in Neoadjuvant Breast Cancer (CTNeoBC).

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