1. From the
ESO-MBC Guidelines Task Force
to the
First Consensus Conference for
Advanced Breast Cancer
Fatima Cardoso, MD
ESO Breast Cancer Program Coordinator
Director Breast Cancer Unit & Breast Cancer Research Program
Champalimaud Cancer Center
Lisbon, Portugal

2. THE MAGNITUDE OF THE PROBLEM
1 out of 8 women
will have BC during their lifespan
Death is (usually) due to distant
metastases
In Europe :
1 diagnosis every 2,5 minutes
1 death every 6,5 minutes

3. Are guidelines needed?
Breast Cancer
Despite ↑ incidence - ↓ mortality
* Screening & early diagnosis
* Education & advocacy
but also
* Better treatment options
* Better treatment strategies

4. BUT
The evolution as been
quite different between
adjuvant and
metastatic settings
WHY?
Different diseases?
Different biology?
Different aims?
Different attitude of
physicians?

5. Advances in EARLY BC are measured in YEARS (DECADES)

6. 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 60
Giordano 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

7. 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-negative
rate/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

8. 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

9. 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.

10. Bridge Survey - Key Findings
MBC Receives Too Little Attention
•Almost 6 in 10 women in Europe feel that MBC receives too little
attention in general, and 54% say EBC receives more attention
than MBC.
•Most women do not feel that healthcare professionals,
researchers, the media, women with EBC, and the governments
pay enough attention to MBC.
•Many women advocate for an increase in a wide variety of MBC-
related educational or support activities, especially support
groups and written materials, but also conferences.

11. Bridge Survey - Key Findings
GUILT! FEAR! LONELINESS!
•Throughout the survey there is a worrying picture of feelings of
guilt, abandonment, isolation, and loneliness during the hard
journey through MBC..
• 44% of respondents reported being afraid to talk open about
their disease and 52% said their friends and family were uneasy
talking about the disease.
• 78% of women living with MBC had never participated in a
clinical trial & 56% of these women were never invited to
consider a clinical trial.
Editorial: Cardoso, The Breast 18 (2009) 271–272

12. TIME TO CHANGE!

13. ESO–MBC Task Force Recommendations
Preparatory 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)

14. 12 Statements ESO-MBC Task Force
The Breast 16, 9–10, 2007

15. 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?

16. 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

17. 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

18. 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.

19. 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

20. 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

21. How can we ensure success of ABC1 guidelines?
What measures do you suggest to increase the implementation
of the international consensus guidelines being developed at
the 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

22. 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

23. 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 GUIDELINES
TOGETHER WE CAN and WE WILL
MAKE THE CHANGE!
MEDIAN SURVIVAL:
from years to decades!