From theESO-MBC Guidelines Task Forceto theFirst Consensus Conference forAdvanced Breast Cancer Fatima Cardoso, MD ESO Breast Cancer Program CoordinatorDirector Breast Cancer Unit & Breast Cancer Research Program Champalimaud Cancer Center Lisbon, Portugal
THE MAGNITUDE OF THE PROBLEM 1 out of 8 womenwill have BC during their lifespanDeath is (usually) due to distant metastases In Europe :1 diagnosis every 2,5 minutes 1 death every 6,5 minutes
Are guidelines needed? Breast CancerDespite ↑ incidence - ↓ mortality * Screening & early diagnosis * Education & advocacy but also * Better treatment options * Better treatment strategies
BUTThe evolution as beenquite different betweenadjuvant andmetastatic settings WHY?Different diseases?Different biology?Different aims?Different attitude ofphysicians?
Advances in EARLY BC are measured in YEARS (DECADES)
OS of MBC pts between 1974 - 2000 1.0 .8 1995-2000 .6 1990-1994 .4 1985-1989 1980-1984 .2 1974-1979 0.0 0 12 24 36 48 60Giordano SH, et al, Cancer 100:44-52, 2004 Months Advances in METASTATIC BC are measured in DAYS – MONTHS (max: few years; median survival MBC= 2-3 yrs) Are MBC guidelines needed? definitely YES
RISK OF RECURRENCE REMAINS PRESENT THROUGHOUT ALL PATIENTS’ LIFETIME 16 14 Saphner T et al. J Clin Oncol 1996; 14: 2738–2746.Recurrence 12 Node-negativerate/year (%) 10 Node-positive 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 Time (years) Are MBC guidelines needed? definitely YES
COMPLIANCE WITH GUIDELINES LEADS TO IMPROVED OUTCOMES• 1,541 women with node(-) disease treated in Quebec 1988-1994• Applied 1992 St. Gallen risk criteria and treatment recommendations• Risk category and compliance with guidelines were significant independent predictors of survival (p<.0005) Hebert-Croteau, et al. JCO 2004
Compliments of Conducted by Wide-reaching assessment of the needs/preferences of 1342 women living with MBC in 13 countries (USA, UK, France, Spain, Poland, Belgium, Mexico, Argentina, Egypt, Australia, Brazil, Canada, Venezuela) On January 25, 2008, the Metastatic Breast Cancer (MBC) Advocacy Working Group comprised of 16 patient advocates groups from 7 countries, convened in New York, to share insights on the current obstacles and discuss potential solutions for better addressing unmet needs of women with MBC.
Bridge Survey - Key Findings MBC Receives Too Little Attention•Almost 6 in 10 women in Europe feel that MBC receives too littleattention in general, and 54% say EBC receives more attentionthan MBC.•Most women do not feel that healthcare professionals,researchers, the media, women with EBC, and the governmentspay enough attention to MBC.•Many women advocate for an increase in a wide variety of MBC-related educational or support activities, especially supportgroups and written materials, but also conferences.
Bridge Survey - Key Findings GUILT! FEAR! LONELINESS!•Throughout the survey there is a worrying picture of feelings ofguilt, abandonment, isolation, and loneliness during the hardjourney through MBC..• 44% of respondents reported being afraid to talk open abouttheir disease and 52% said their friends and family were uneasytalking about the disease.• 78% of women living with MBC had never participated in aclinical trial & 56% of these women were never invited toconsider a clinical trial. Editorial: Cardoso, The Breast 18 (2009) 271–272
ESO–MBC Task Force RecommendationsPreparatory work:Task Force created; meetings; some decisions: 1. MBC guidelines cannot be rigid 2. Should be built on principles and not on specific treatment regimens 3. Need to be in line with latest research findings (biology…) 1st Session: EBCC-4 (Nice, March 2006): Are MBC guidelines possible? YES 1st step: 12 Statements (Principles)
12 Statements ESO-MBC Task Force The Breast 16, 9–10, 2007
ESO–MBC Task Force Recommendations 2nd Step: Discuss each statement in detail and provide recommendations for each specific topic 2nd Session: EBCC-5 (Berlin, April 2008) 1. Can metastatic breast cancer be cured? 2. Management of CNS metastases: A new era for a growing problem 3. Treating metastatic breast cancer: Is more always better?
ESO–MBC Task Force Recommendations Cardoso et al, J Natl Cancer Inst 2009; 101: 1174–1181 Pagani O, Senkus E, et al. J Natl Cancer Inst 2010; 102: 1–8 Manuscripts available in www.abc-lisbon.org
ESO–MBC Task Force Recommendations 2nd Step: Discuss each statement in detail and provide recommendations for each specific topic 3rd Session: EBCC-7 (Barcelona, March 2010)1. Follow-up issues in MBC: a. How should MBC be followed? b. Should MBC be diagnosed as early as possible?2. Open questions on chemo and endocrine therapies in MBC: a. What patients need their doctors to focus on? (patient and doctor perspective) b. How many lines of therapy should be given? c. Role of maintenance therapy Manuscripts in preparation
TIME TO CHANGE!Do ABC1 attendees agree? With the enthusiastic support of Eisai. A very special THANK YOU to Susan McCutcheon! … and to all who answered the survey.
So far, 224 Responses from over 50 countries (72% are Healthcare Professionals)Over 80% agree that generally the treatment of ABC is not as high profile, as early BC In your opinion, why is treatment of ABC not as high profile, as early BC? Lack of clinical trials in this area Lack of clear and applicable management guidelines Lack of patient motivation Lack of charity work targeted at ABC Lack of funding for treatments Lack of clinical resources Less of a governmental priority Lack/less of advocacy involvement Lack of high level evidence for treatment options It is too challenging Lack of clear treatment goals 0.00 0.50 1.00 1.50 2.00 2.50 3.00
NCCN and ESMO guidelines are used by many but not all & there are gaps Why would international consensus guidelines for ABC be useful?80.0%70.0%60.0%50.0%40.0%30.0%20.0%10.0%0.0% Would not be Help improve Help ensure Help ensure Help ensure Help improve Other (please of help patient consistency of funding consistent resource specify) outcomes care available for training and allocation for the optimal education of ABC management health care of ABC providers
How can we ensure success of ABC1 guidelines?What measures do you suggest to increase the implementationof the international consensus guidelines being developed atthe ABC1 conference worldwide? Publication Patient Advocacy Involvement Good Quality Guidelines On-going Education Regionally and Locally Lobbying Government and Health Care Providers Use Digital Media / Internet to Spread Adoption by Other Groups (NCCN, ESMO, WHO etc) Widespread Circulation to all Oncologists
TIME TO CHANGE!Apply the main principles of modern oncology: Multidisciplinary treatment Specialized breast cancer units Evidence-based medicine (please STOP “eminence-based” medicine!!) Individualized (tailored) therapy Remember the specificities of ABC setting Patient’s preferences & active participation
TIME TO CHANGE! IT IS OUR RESPONSIBILITY REACH THE CONSENSUS GUIDELINES APPLY THE GUIDELINES IN OUR CLINICAL PRACTICE SPREAD THE WORD! DEMAND (specially advocates!) IMPLEMENTATION OF GUIDELINESTOGETHER WE CAN and WE WILL MAKE THE CHANGE! MEDIAN SURVIVAL: from years to decades!