Quick Links
Past Events

Credit Designation

Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC designates this live activity for a maximum of 26.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Acknowledgment of Commercial Support

This activity is supported by educational grants from Celgene Corporation, Eisai Inc., Genentech, and Novartis Pharmaceuticals Corporation.
Privacy Policy
Terms & Conditions
Executive Board
Faculty Portal
Google +
2 Clarke Drive
Suite 100
Cranbury, NJ 08512
P: 1-609-378-3701

Copyright © 2018
Physicians’ Education Resource ®, LLC.
All rights reserved.

31st Annual Miami Breast Cancer Conference®

31st Annual Miami Breast Cancer Conference®


31st Annual Miami Breast Cancer Conference®: Meeting-in-a-Box
The Meeting-in-a-Box components are designed for you to share the information with colleagues, fellows, and other health care professionals.

PER Pulse™ Recap
Three PER Pulse™ Recaps presenting key topics from the 31st Annual Miami Breast Cancer Conference®, which was held on March 6 - 9, 2014.

PER Meeting in a Box

Presentation Title Faculty Discussion Questions
A Non-Hormonal Approach to Prevent Vulvovaginal Atrophy in Women With AIs Leslie Schover, PhD Do you discuss the importance of adherence to full treatment period with your patients who are on aromatase inhibitors (AIs)? Do you specifically ask your patients on AIs about sexual function?
What Is the Future of HER2 as a Target in Breast Cancer?
Faculty has not granted permission to post this presentation
Sunil Verma, MD, MSEd, FRCPC Approximately what percentage of patients in your practice have HER2-positive breast cancer? Do you routinely retest your patients for HER2 when their disease spreads or reoccurs?
Tomosynthesis 3-D Mammography: Do You Need It in Your Practice?
Faculty has not granted permission to post this presentation
Christina Giuliano, MD What are the implications of incorporating tomosynthesis
3-D mammography into clinical practice? Do the benefits of increased screening sensitivity outweigh the risks of increased radiation exposure, or should it be limited to use in specific patients? Can earlier diagnosis of invasive breast cancers significantly improve prognosis?
Cancer Stem Cell Update Lance A. Liotta, MD, PhD What has Dunn’s research taught us about the therapeutic implications of cancer stem cells? What are the clinical implications of identifying cancer stem cells in patients with ductal carcinoma in situ? What is the rationale for targeting cancer stem-like cells for the treatment of pre-invasive breast lesions?
How I Assess Symptoms in Breast Cancer Survivors in a Very Busy Clinic Hyman B. Muss, MD Do you utilize a checklist to capture patient-reported symptoms in your practice? What are the clinical implications of the Basch trial regarding the accuracy of patient-reported symptoms?
Sexual Dysfunction in Women with Breast Cancer: An Internet-Based Intervention Leslie Schover, PhD Do you routinely assess sexual function in your patients before and after treatment? Do the results from the TENDRILS efficacy trial have any implications for clinical practice?
Oncologic and Aesthetic Outcomes of Oncoplastic Breast-Conserving Surgery
Faculty has not granted permission to post this presentation
R. Douglas Macmillan, MD, MB ChB, FRCS Do you recommend wide local excision (WLE) to your patients with small breast cancers? Are there patients for whom this option is not recommended? Do the data comparing oncologic outcomes with breast-conserving surgery versus mastectomy assuage patient fears?
The Great Margin Counterpoint Melvin J. Silverstein, MD, FACS How would you proceed in a patient with a margin <1 mm from ink? What margin widths do you believe constitute complete excision? Are there any patients for whom you would not recommend radiation therapy following lumpectomy?
Current Status of Accelerated Partial-Breast Radiation Julia White, MD How do distant failure rates compare in patients treated with APBI versus WBI? Approximately what percentage of your patients experience recurrence after APBI?
The New Definition of Surgical Margins Jay R. Harris, MD Approximately what percentage of your patients undergo re-excision due to inadequate margin? Do you agree with the data that indicate that no ink on tumor is sufficient margin for resection in the majority of patients with invasive breast cancer? For which patients are wider margins clearly indicated? What are the factors to be considered for re-excision?
Genetic Testing Post-Angelina Jolie and the SCOTUS Decision Ellen T. Matloff, MS, CGC How often do you recommend genetic testing to your patients? Is unusual presentation sufficient reason to prompt genetic testing? What criteria do you use for selecting a laboratory for genetic testing? Do you consider BART testing for patients who were tested for BRCA mutations prior to 2002? Are the clinical implications of cancer risk in patients with BRCA2 enough to justify genetic testing?
A Rational Approach to MRI in Clinical Practice
Faculty has not granted permission to post this presentation
Christina Giuliano, MD What criteria do you use for recommending MRI as a diagnostic tool for your patients with breast cancer? Do you routinely utilize MRI in patients with positive margins? Can annual MRI screening improve outcomes in high-risk patients?
Breast Cancer as a High-Stress and High-Volume Career Choice: Identifying and Managing Burnout Henry Kuerer, MD, PhD, FACS Do the statistics on burnout among oncologists align with your clinical experience? Does your institution have formal programs in place to prevent and address burnout?
Documentation in the Era of Pay-for-Performance: Information Technology and EHR Update Kevin Hughes MD, FACS In your experience, are EHRs helping or hindering patient care? Does your practice utilize the services of an EHR vendor?
Role of Genomic Profiling in Minimally Node-Positive Breast Cancer Kathy S. Albain, MD, FACP What are the strengths and weaknesses of genomic profiling? How can data concerning the biology of pathway activation further enhance outcome?
How Long Do I Continue Anti-Estrogen Therapy -- 5 Years, 10 Years, Forever? Harold J. Burstein, MD, PhD Have the ATOM and AXOMM data influenced your treatment decisions? What factors do you consider when deciding whether or not to continue tamoxifen therapy?
Targeting HER2 in 2014: Early-Stage Breast Cancer
Faculty has not granted permission to post this presentation
Sunil Verma, MD, MSEd, FRCPC Should all patients with early-stage breast cancer be tested for HER2? Are there enough data to warrant continuation of trastuzumab for more than the standard 1 year?
Maximizing Cardiac Function on HER2-Targeted Therapy: Proactive Use of ACE Inhibitors or Beta-Blockers Hyman B. Muss, MD Is there an optimal approach to monitoring for cardiac toxicity? What is the prognostic value of subclinical cardiac disease? Do you refer patients with mild decline in LVEF to a cardiologist?
Causes and Treatments of Low Sexual Desire in Breast Cancer Survivors Leslie Schover, PhD Do you perceive sexual dysfunction to be a significant cause of distress in your patients with breast cancer? Does the risk of recurrence negate the role of androgens in HRT?
Innovations in Neoadjuvant Therapy: Platinum in Triple-Negative; HER2-Targeted mAbs for HER2-Positive Harold J. Burstein, MD, PhD In which patients do you use neoadjuvant therapy? Is there currently a role for pertuzumab as neoadjuvant therapy in HER2-positive patients?
Should "Adjuvant" Bisphosphonates Ever Be Used? Debu Tripathy, MD Is there currently a role for bisphosphonates as adjuvant therapy in patients with bone metastases? What do the data tell us about bisphosphonate use in patients currently on aromatase inhibitors? Do the data clearly indicate recurrent and mortality benefit in post-menopausal women? Is there a certain patient profile for whom bisphosphonate therapy is more feasible?
Application of Proteomics to Biomarker Discovery and Individualized Therapy Lance A. Liotta, MD, PhD Is there any promise for utilizing biomarkers for the detection of early-stage breast cancer? How can analysis of protein biomarkers in tissue samples guide treatment decisions?
What Have We Learned About the Biology of Breast Cancer From Clinical Trials? Donald L. Weaver, MD Is it reasonable to withhold anthracycline therapy in certain subsets of patients? Which ones and why? What are the efficacy data of paxlicatel + trastuzumab given weekly as adjuvant therapy?
Newer Personalized Therapies on the Horizon for Advanced Breast Cancer Debu Tripathy, MD How has next-generation genome sequencing revolutionized clinical cancer care and investigations? What strategies can be employed to block molecular pathways in order to overcome resistance? Is there a rationale for treating patients with multiple drug regimens?
Individualizing Therapy in Metastatic Breast Cancer Through Genomics and Proteomics Lance A. Liotta, MD, PhD Do you routinely biopsy the metastatic tumor or the primary tumor to guide treatment decisions? What role does genomic analysis play?
The Great Mammography Debate Patrick I. Borgen, MD Do you believe routine mammography screening has resulted in a reduction in breast cancer mortality in your clinical practice? What are some flaws of the Canadian National Breast Screening Study that call into question the validity of its conclusions?
Ablative Radiotherapy for Oligo-Metastatic Disease Julia White, MD Is there currently a role for multidisciplinary treatment of oligo-metastatic disease? Is there a subset of patients with oligo-metastatic disease for whom ablative radiation therapy is indicated?
Genomic Profiling of Tumors and Loco-Regional Recurrence Eleftherios Mamounas, MD, MPH, FAC What is the rationale for genomic profiling in early-stage breast cancer for both node-negative and node-positive patients? Is there currently a role for genomic profiling in patients with ductal carcinoma in situ?
Selecting Systemic Therapy in BRCA Heterozygotes With Breast Cancer
Faculty has not granted permission to post this presentation
Mark Robson, MD Is there a role for platinum-based chemotherapy in patients with BRCA mutations? What is the rationale behind investigations of PARP inhibition?
Bringing New Drugs to the Pre-Surgical Setting: Challenges and Opportunities Kathy S. Albain, MD, FACP How has the accelerated approval of new cancer drugs complicated therapeutic decision-making in your practice? How do you remain up-to-date on the rapidly changing treatment landscape?
Management of Patients With Involved Axillary Nodes J. Michael Dixon, MD, OBE What are some alternatives to axillary node dissection? Are there clinical trial data to support the role of axillary radiotherapy in patients with involved axillary nodes?
Implications for Axillary Radiation Following Review of the ACOSOG Z-11 Trial
Faculty has not granted permission to post this presentation
Judy C. Boughey, MD What are the key learnings from the ACOSOG Z-11 trial? How can axillary radiation be tailored to patients with very low, moderate, and very high risk?
Human Subjects Implications of Genomic Profiling of Tumors Joyce O'Shaughnessy, MD What are some of the new data sets concerning the clinical utility of genomic profiling, and what are their implications for clinical practice?
The Great Margin Debate Melvin J. Silverstein, MD, FACS In patients with invasive cancer, when is excision alone an acceptable treatment modality? What selection criteria can be used to select patients for radiation therapy?
Targeting HER-2 in Metastatic Breast Cancer in 2014 Kimberly Blackwell, MD What do the data from CLEOPATRA tell us about pertuzumab and its potential role in the treatment of metastatic breast cancer? What is the role of T-DMI?
Breast Conservation in Patients With Multiple Ipsilateral Tumors
Faculty has not granted permission to post this presentation
Judy C. Boughey, MD What have we learned about the pathogenesis of multifocal and multicentric breast cancers? What are the inherent challenges of staging multiple ipsilateral tumors? What is the clinical impact of recent data that do not confirm higher local recurrence rates in multicentric breast cancers?
Stage vs Biology: What Drives Adjuvant Treatment Decisions? Kathy S. Albain, MD, FACP How does the role of biology vary in low-risk and high-risk disease? What strategies can be employed to improve survival in high-risk patient groups?
Who Should Get Post Mastectomy Radiation Therapy? Jay R. Harris, MD Is the survival benefit of post mastectomy radiation therapy linked to a reduction in local recurrence? Do clinical trials demonstrate benefit of systemic therapy post mastectomy?
Risk-Reducing Mastectomy: Where Are We in 2014? Donna-Marie Manasseh, MD What role does the patient play in choosing mastectomy versus breast-conserving surgery? What are the indications for nipple-sparing mastectomy?
Identification of Genetic Lesions in Strong Positive Family History, BRCA-Negative Patients -- Multigene Panels
Faculty has not granted permission to post this presentation
Mark Robson, MD What prospective benefit is there to multi-gene testing as a diagnostic tool? Do the benefits outweigh the uncertainties? Which patients are ideal candidates for multi-gene testing?
Chair Emeritus Keynote Lecture: Wrong Medicine -- Why Do We Pursue Futile and Costly Overtreatments? Lawrence J. Schneiderman, MD Does your institution have a medical futility policy? When do you introduce discussions of comfort care into your dialogue with your patients? Is the need for medical rationing an issue you face frequently in practice?
Keynote Lecture: New Times, New Strategies -- Maximizing the Research Investment Judith A. Salerno, MD, MS How can collaboration among organizations help us to capitalize on research investments? What strategies can be employed to support the next generation of physician investigators?

PER Pulse™ Recap PER Pulse™ Recap
Medical Writer: Laurie Orloski, PharmD
1 of 3
PER Pulse Recap
31st Annual Miami Breast Cancer Conference®

The multidisciplinary Miami Breast Cancer Conference® has been bringing together surgical, medical, and radiation oncologists for 31 years, with the aim of fostering awareness of the state-of-the-art treatments in each therapeutic area and encouraging cross-team cooperation in the clinic. This first of 3 PER Pulse™ Recaps focused on the 31st Annual Miami Breast Cancer Conference® examines selected surgical issues, including those related to clinical progress with breast-conserving therapy (BCT) as discussed by Drs. Donna Marie Manasseh and Dr. Grant Carlson, the benefits and risks of contralateral prophylactic mastectomy (CPM) by Dr. Carlson, and the use of lipofilling for patients undergoing post-mastectomy breast reconstruction and breast edema by Dr. Mike Dixon.

Dr. Donna Marie Manasseh specifically addressed the question as to when BCT is not the best option for early breast cancer. After noting that there are cases where mastectomy and reconstruction can provide a better cosmetic result as well as the important principle of maintaining cosmesis, she explained how good cosmesis is largely driven by the percentage of tumor volume. Overall, the ratio of tumor size to breast size is still paramount in selecting patients for BCT with good cosmesis, with determination of actual breast volume dependent upon use of imaging. It is also important that intentions and expectations of the patients be addressed, including those based on breast attachment (sexuality), cosmesis, fear of unknown results, and the importance of the nipple-areolar complex (NAC) to a given patient.  Much of the presentation was devoted to the special issues surrounding augmented breasts, a setting in which BCT may be less optimal from a cosmesis standpoint. Augmentation increases breast size but not the amount of breast tissue, and, on this basis, “what you may be seeing is not what you may be getting.” Nipple-sparing mastectomy (NSM) may be a good choice in these patients. In cases of small glandular breast tissue, it may be worthwhile to take an approach of removing the parenchyma and avoiding radiation therapy (RT). The concluding points emphasized the importance of considering baseline volume as part of the surgical plan for augmented patients, and that, overall, BCT is not just oncologic, but a cosmetic procedure as well.

Dr. Grant Carlson focused his discussion on the tumor biology and surgical considerations around the use of NSM, for which only limited data have been available until recently. It is well recognized that patient satisfaction following NAC reconstruction tends to be disappointing, yet the heterogeneous surgical techniques and patient selection with NSM, as well as short-term follow-up times, have collectively hindered the evaluation of oncologic outcomes. Whereas skin-sparing mastectomy (SSM) has wide applicability for a broad range of tumors and patients and proven oncologic safety, NSM should be reserved for small to small-to-moderate breasts and has unproven oncologic safety, but may have the potential for improved cosmesis. Dr. Carlson explained that the NSM story began with a 1999 publication by Hartmann et al from the Mayo Clinic involving 639 high-risk patients undergoing bilateral prophylactic mastectomy, in whom only 1 of 7 cases of invasive breast cancer was associated with the NAC. A number of other studies have shown a low rate of NAC recurrence with adequate follow-up periods. Clinically, it is critical to know the depth of the primary tumor in considering NSM, which will be influenced by breast size and shape. Overall, NSM has a role in the treatment of breast cancer; however, proper patient selection and surgical techniques are essential.

In a separate talk, Dr. Carlson reviewed the role of risk-reducing CPM with immediate reconstruction, addressing both added risks and added benefits. In reviewing predictors of CPM, study data are available to support that women who choose CPM are more often young, white, and have a family history of breast cancer. Use of preoperative magnetic resonance imaging (MRI) was also a positive predictor, whereas prior attempt at breast conservation was a negative predictor; tumor characteristics such as histology and stage had no influence on the choice of CPM. Dr. Carlson explained that the use of CPM does not eliminate the risk of contralateral breast cancer and does not markedly improve survival. Nonetheless, major reasons underlying the decision to undergo CPM may include the fear of recurrence and the desire to avoid RT, along with additional reasons such as the alleviation of patient anxiety and the ability to limit future diagnostic imaging/biopsies, especially in younger patients. He went on to highlight findings regarding aesthetic satisfaction, illustrating that the durability of autologous reconstruction stays with and ages well with patients. Conversely, results with unilateral implant reconstruction deteriorate over time. As a major shortcoming, however, it is estimated that about one in four CPMs are associated with some form of breast complications, and that there is an approximate twofold increase in complications when comparing CPM with unilateral reconstruction. While there is no clear answer as to the best choice of procedure, it is critical that patients be educated about these issues to aid in the decision-making process. 

Dr. Mike Dixon covered the topic of lipofilling for breast reconstruction and breast edema. With prior use of implants for augmenting volume in larger-breasted patients, lipofilling had been shown to improve the final results. His experiences have shown that in the setting of delayed reconstruction after RT, when skin quality tends to be poor, lipofilling can bulk out and rejuvenate mastectomy-irradiated latissimus dorsi (LD) flaps. Additionally, in patients planning to undergo RT, his use of lipofilling in LD flaps has been shown to substantially improve skin quality. Dr. Dixon also showed a positive result with lipofilling for a case of breast edema, a complication that occurs in about 10%-21% of patients undergoing breast-conserving surgery/RT–yet remains as an underrecognized problem associated with significant pain and morbidity, but few good treatment options.

2 of 3
PER Pulse Recap
31st Annual Miami Breast Cancer Conference®

The multidisciplinary Miami Breast Cancer Conference® has been bringing together surgical, medical, and radiation oncologists for 31 years, with the aim of fostering awareness of the state-of-the-art treatments in each therapeutic area and encouraging cross-team cooperation in the clinic. This second of 3 PER Pulse™ Recaps focused on the 31st Annual Miami Breast Cancer Conference® examines selected medical issues, including those related to the targeting of HER2 in early-stage breast cancer in 2014 as discussed by Dr. Sunil Verma, two separate topics of innovations in neoadjuvant therapy and the duration of antiestrogen therapy by Dr. Harold Burstein, and the use of adjuvant bisphosphonates by Dr. Debu Tripathy.

Dr. Sunil Verma began his presentation by reviewing the series of early adjuvant trastuzumab studies initiated during the years 1999-2001. Favorable data supporting adjuvant trastuzumab were presented around 2005, with the caveat that longer follow-up was needed beyond the median of 1 year. With continued follow-up to 8 to 8.5 years, the benefits of adjuvant trastuzumab have been maintained, with consistent improvements in both disease-free survival (DFS) and overall survival (OS), as well as more significant effects of an anthracycline/taxane/trastuzumab regimen versus a sequential or nonanthracycline approach. The OS benefit of adjuvant trastuzumab has been shown to be irrespective of hormone receptor (HR) status. In terms of duration, several studies collectively support the commonly studied 1-year trastuzumab backbone, as there have been no observations favoring a 2-year course or shorter durations overall; however, based on the PHARE trial of 6 months versus 1 year of adjuvant trastuzumab, which failed to demonstrate noninferiority for the shorter course, there was a hypothesis-generating signal suggesting the applicability of 6 months of therapy in certain subgroups (ie, tumors <1 cm, HR-positive disease, and receipt of concurrent therapy). The issue of optimal duration continues to be explored in clinical trials.

There has been ongoing interest in nonanthracycline adjuvant therapy in light of associated cardiac toxicity of anthracycline agents, with data from the BETH trial supporting a remarkably high 3-year DFS rate of 96% in a population that was mostly treated with nonanthracycline adjuvant chemotherapy. Other research efforts have been seeking to develop adjuvant regimens lacking both docetaxel and carboplatin, which was undertaken in the recently reported APT trial of adjuvant weekly paclitaxel and trastuzumab in HER2-positive, node-negative disease with a primary tumor ≤3 cm. With this nonanthracycline regimen, the 3-year recurrence-free rate was 99.2%, meeting the prespecified rate of <5% to support efficacy. It may be reasonable to apply this regimen to patients with cardiac risk factors or cardiac disease, those with a low likelihood of absolute benefit from adjuvant therapy, and older patients using a threshold of approximately age >70 years.

Other trials are exploring a dual HER2-targeted approach and the ability to avoid the use of chemotherapy entirely. Overall, 1 year of trastuzumab is a component of the standard of care for adjuvant breast cancer therapy, promising data are emerging for nonanthracycline regimens (which may be considered for certain patients, but with assessment of disease risk and cardiac toxicity risk), and ongoing trials will help evolve the treatment options moving forward.

Dr. Harold Burstein discussed innovations in neoadjuvant therapy, by first reviewing the FDA guidance regarding accelerated approval of breast cancer agents based on results in the neoadjuvant setting. This guidance is based on the use of pathologic complete response (pCR) as a surrogate endpoint, with full approval ultimately relying on a demonstrated improvement in long-term outcomes of DFS and/or OS. Importantly, however, there have been no estimates as to the extent of pCR improvement that would translate into improved DFS and OS. Dr. Burstein reviewed a series of studies of pertuzumab that together supported the FDA approval of this agent as neoadjuvant therapy for HER2-positive breast cancer; interestingly, however, the National Comprehensive Cancer Network (NCCN) guidelines extend the applicability of pertuzumab to the adjuvant setting, based on a footnoted recommendation.

Several clinical trials, including cooperative group trials, have shown that bevacizumab increases the pCR rate in the neoadjuvant setting, and that platinum agents increase the pCR rate specifically in triple-negative disease. None of the trials of pertuzumab (nor of bevacizumab or platinum agents) met the FDA’s criteria for accelerated approval, yet pertuzumab was approved on the basis of an observed signal in the neoadjuvant setting, an OS benefit in metastatic disease, and favorable safety findings. Additionally, the adjuvant APHINITY study had already been completed, for which results will be forthcoming in the near future. Nonetheless, the current situation represents a clinical dilemma given the lack of clear benefit of adjuvant use of pertuzumab, along with the fact that the NCCN recommendation appears as a mere footnote, and thus does not represent strong guidance for evidence-based care. While neoadjuvant pertuzumab is indicated for use in HER2-positive breast cancer, its use in the adjuvant setting needs to be considered on a case-by-case basis in clinical practice, by addressing such real-world issues as insurance coverage.

Dr. Debu Tripathy discussed the rapidly evolving area and clinical question as to whether adjuvant bisphosphonates should be used in clinical practice. There is a paucity of insight into bone biology in breast cancer. Bone is a common site of metastatic disease, and several cells are known to serve as regulators of bone turnover. Bisphosphonates were approved for managing bone metastases because of their ability to reduce bone turnover and reduce skeletal event rates. Early evidence for clodronate in the adjuvant setting showed that, after 2 years of therapy, there were reductions in distant metastases, bony metastases, visceral metastases, and death relative to placebo. Similar benefits were shown in other small trials but not in the large NSABP B-34 study and subsequent studies of ibandronate, representing the next generation of bisphosphonates. Clinical trial reports of the widely studied agent zolendronate have collectively yielded mixed results, with evidence of reduced recurrence rates in analyses of studies (Z-FAST, ZO-FAST, and ABCSG-12) but no DFS benefit in another (AZURE).

Subsequently, a meta-analysis was conducted to address the efficacy of adjuvant bisphosphonate therapy, pulling individual data from randomized trials. Recent reported results showed that there were small but significant 10-year gains in the rate of distant recurrence in all women (1.4%) and recurrence specifically in bone (1.5%), with larger corresponding improvements in these parameters in the postmenopausal subset (3.5% overall and 2.9% for bone). The postmenopausal group had 10-year gains of 3.1% for breast cancer mortality and 2.3% for all-cause mortality. Overall, data regarding the benefits of adjuvant bisphosphonates are mixed, leaving unanswered questions that complicate clinical decision making. At the same time, however, subset analyses have consistently shown recurrence benefit in postmenopausal patients, as confirmed in a recent meta-analysis. Use of adjuvant bisphosphonate therapy may be well suited for those patients who are high risk, motivated, and understand the associated risks (which include a small but real risk of osteonecrosis of the jaw).

Another clinical question that was addressed is the optimal duration of antiestrogen therapy (5 years, 10 years, or forever), as covered by Dr. Burstein. After first leading in with a review of the issue of timing of recurrence, Dr. Burstein addressed the rationale for the recommended 5-year course of tamoxifen. NSABP-B14 and two other trials together suggested no benefit for treatment with tamoxifen beyond 5 years, with some evidence that a longer duration may be detrimental. These initial trials were followed by a series of studies addressing the comparability of 5 years of tamoxifen versus 5 years of aromatase inhibitor (AI) therapy as well as continued tamoxifen versus switching to an AI, with additional interest in elucidating the potential of 5 years of tamoxifen followed by 5 years of an AI.

As data were emerging to support modest benefits for AIs such as letrozole and exemestane in reducing recurrence, data were pending from two ongoing large trials of 10 years versus 5 years of tamoxifen: the global ATLAS trial and the UK-based aTTom trial. There was a reduction in the rate of recurrence and a small OS benefit for extended tamoxifen in ATLAS, whereas a reduction in recurrence was accompanied by a trend for reducing breast cancer deaths but not overall mortality in aTTom. Antiestrogen therapy has a finite period given the side-effect profiles of both tamoxifen (including thromboembolism and uterine cancer) and AIs (including osteoporosis, myalgias, and arthralgias).

An approach to treating patients based on menopausal status would be as follows. For premenopausal patients, initiate tamoxifen and continue for 5 years, at which point it could be continued for another 5 years if patients are still premenopausal, or even if they are postmenopausal; however, if definitively postmenopausal, another option would be to switch to an AI. Postmenopausal patients should be given the option of tamoxifen or an AI, using the adverse-event profiles to guide the decision. Most patients will communicate a preference. Those selecting upfront tamoxifen could continue tamoxifen as extended therapy or switch to an AI after the first 5 years of tamoxifen. For those selecting upfront AI, no data are currently available to support a duration beyond 5 years; after 5 years, some patients may be content to discontinue therapy whereas others may be in favor of further treatment, at which point it would be reasonable to consider granting a short extension for 1 year or even 2 years. These durations assume that the treatment is well tolerated; if not, then treatment discontinuation may be warranted. As an important final point, adjuvant antiestrogen therapy is an evolving area affecting a large population of patients classified as cancer survivors; accordingly, mechanisms must be in place to ensure that any amended treatment standards are communicated to patients who may have already transitioned to primary care.

3 of 3
PER Pulse Recap
31st Annual Miami Breast Cancer Conference®

The multidisciplinary Miami Breast Cancer Conference® has been bringing together surgical, medical, and radiation oncologists for 31 years, with the aim of fostering awareness of the state-of-the-art treatments in each therapeutic area and encouraging cross-team cooperation in the clinic. This third of 3 PER Pulse™ Recaps focused on the 31st Annual Miami Breast Cancer Conference® examines several different types of screening issues, including those related to mammography as discussed by Dr. Patrick Borgen, genetic testing by both Dr. Mark Robson and Ms. Ellen Matloff, and the assessment of symptoms among breast cancer survivors in day-to-day practice by Dr. Hyman Muss.

Dr. Patrick Borgen discussed the most recent mammography debate, stemming from the published 25-year follow-up results of the Canadian National Breast Screening Study (CNBSS) and resultant major media attention (collectively questioning the value of mammography on the basis of the CNBSS findings). In the CNBSS, women aged 40-59 years were randomized to undergo or not undergo screening mammography between 1980 and 1985. All patients were required to undergo a clinical examination by trained doctors or nurses at study onset. Dr. Borgen emphasized that this was an important component of the study design—as allocation to screening or the control arm allowed for discretion by these same clinicians, with compelling evidence that patients with clinically detectable lumps were more likely to be entered into the screening arm. The results showed that 666 invasive cancers were diagnosed in the mammography arm versus 524 cases in the control arm, with no evidence of downstaging based on tumor size or reduction in mortality.

The CNBSS authors called for a reassessment of the value of screening mammography, concluding that any benefit of a mammography-only screening program is derived from the discovery of cancers that are detectable by a thorough breast examination, and that annual mammography does not reduce breast cancer mortality for women aged 40-59 years. Dr. Borgen discussed the issues with the findings and resultant conclusions, noting that the results failed to explain reductions in breast cancer mortality observed since 1990 and those that have been documented in larger, better designed trials. Additionally, the study authors did not acknowledge the patient allocation bias, limitations of the older technology, lack of technician training and experience, and lack of statistical power. Importantly, the study provided no funding for modern equipment and no special training for technicians and radiologists. An external review for the first four years of the study found that 50% of the readings were poor or not interpretable, and sensitivity during the 5-year period never exceeded 30% (70% false-negative rate). Dr. Borgen concluded by noting that higher quality trials have demonstrated a 25% reduction in the risk of dying from breast cancer that was attributable to screening mammography, as well as a steady decline in breast cancer mortality since 1990 in virtually all age groups—calling into question the applicability of the CBNSS report, not the value of screening mammography.

Ms. Ellen Matloff discussed genetic testing for BRCA1/2 mutations, an area that she says has seen more positive movement in the past 10 months than in the past decade. This new focus stems from the publicity surrounding actress Angelina Jolie, who in 2013 revealed that she carries a BRCA mutation and opted for a prophylactic mastectomy. Ms. Matloff noted that about 10% of breast cancers are thought to be hereditary, also reviewing the risk factors that make patients suitable candidates for BRCA testing, such as early-age onset (ie, age ≤50, even without a family history), multiple affected family members, family history of related cancers, patient history of multiple primaries, unusual presentation (eg, male breast cancer), ethnicity of Jewish decent, and pathology showing triple-negative breast cancer. Both BRCA1 and BRCA2 mutations increase the risk of not only breast cancer but also a second primary breast cancer and ovarian cancer, while also increasing the risk of male breast cancer (especially BRCA2), prostate cancer, and pancreatic cancer. For patients testing BRCA-positive, options for breast cancer risk management includes surveillance, chemoprevention, and prophylactic surgery. The same types of options also apply to ovarian cancer risk management, although surveillance is not as reliable relative to breast cancer.

In addition to the "Angelina Jolie effect," the Supreme Court ruling that invalidated gene patents was another key development for genetic testing in 2013. The area of genetic testing is becoming increasingly complex with the increasing number of genes that can accompany BRCA testing; at the same time, however, it is providing a new avenue for personalized medicine, whereby the timing of screening tests can be tailored based on predicted cancer risk. The use of such multigene panels was addressed in a separate presentation by Dr. Mark Robson, who focused on the identification of genetic lesions in BRCA-negative individuals with a strong family history of breast cancer. Dr. Robson explained that while there are several high-penetrance genetic syndromes that are detectable by physical symptoms or family history (eg, P53, PTEN, CDH1, STK11), there is another group of moderate-penetrance variants (eg, ATX, CHEK2, PALB2) that are not necessarily rare but are much more difficult to detect and decipher in terms of clinical implications. With this latter group of mutations, family history tends to be less dramatic, and there usually is no clear pattern of non-breast cancers, as well as no physical phenotype. The increase in relative risk with these moderate-penetrance variants is generally modest and may not justify a change in approach to patient care, thereby questioning the clinical utility of testing.

Dr. Robson reviewed additional challenges that are surfacing with the changing paradigm of multigene testing, including the potential desire for some patients to "opt out" of certain findings, the complexity of differentiating risk on the part of both patients and clinicians, uncertainties regarding variance of undetermined significance, and the implications of “off-target genes” that relate to cancers other than breast cancer. Overall, it is clear that multigene testing will identify more germline mutations than testing guided by phenotype and family history; however, whether these tests will improve outcomes is unclear, and there are informational issues to be addressed. Studies are needed before these multigene panels can become standard of care.

Dr. Hyman Muss addressed the approach to assessing symptoms among breast cancer survivors in a very busy clinic setting. After first outlining the current challenges facing physicians, including less face-to-face time with patients, more patients on long-term therapy such as endocrine agents, and the advancing age of the breast cancer population (resulting in more comorbidities), Dr. Muss shifted to solutions to maximize office time. One strategy that he has found to be worthwhile is the development of a symptoms checklist, capturing up to 20 common symptoms that can then be matched with the National Cancer Institute Common Toxicity Criteria for severity (after simplifying the language). Dr. Muss discussed the accuracy of patient-reported outcomes, noting the extent to which they differ from clinician-assessed outcomes and their important association with functional loss, and emphasized the importance of obtaining a baseline assessment of common symptoms (eg, fatigue) very early on in patient management. While symptom reporting has historically been based on clinician assessment, the future research database may also include reporting of symptoms directly from patients. Dr. Muss concluded that capturing symptoms is feasible and can be efficient during a busy clinic visit with the use of a symptoms checklist, which can be done on paper or electronically and can be made part of the patient record, and that patient-reported symptoms should be regarded as being accurate. Moving forward, the next step will be to pair specific symptoms with appropriate interventions.

Physicians' Education Resource®, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

This activity is not approved for AMA PRA Category 1 Credit™.

This activity is supported by educational grants from Celgene Corporation, Eisai Inc., Genentech, and Novartis Pharmaceuticals Corporation.

Become a Member

Forgot Password?
Calendar of Events
Filter By