ABC 1 (1st International consensus guidelines for advanced breast cancer): A positive step

Patients with advanced breast cancer are in a difficult situation indeed. Such men and women have disease which is currently considered incurable although many treatments can be offered. A broad and effective range of therapies are already available and new drugs being introduced for breast cancer are almost always given first to patients in this setting. However, it is crucial for women with advanced breast cancer that all possible therapies and approaches are made as widely and consistently available as possible. As mentioned in these guidelines,1Cardoso F. Costa A. Norton L. et al.1st International consensus guidelines for advanced breast cancer (ABC 1).The Breast. 2012; 21: 242-252Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar patients with metastatic disease are too often overlooked, with more attention being paid to the more glamorous setting of adjuvant therapy where “cure” is possible. Furthermore, progress has been slow in metastatic disease with the median overall survival for patients with metastatic breast cancer still between two and three years, although many live much longer and in much better health than previously. There have not until now been International consensus guidelines for advanced or metastatic breast cancer. Hence the publication of these guidelines1Cardoso F. Costa A. Norton L. et al.1st International consensus guidelines for advanced breast cancer (ABC 1).The Breast. 2012; 21: 242-252Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar is a very positive development. Work on these guidelines began when the European School of Oncology (ESO) created an Advanced Breast Cancer (ABC) Taskforce in 2005 aiming:1)to develop International consensus guidelines for the management of ABC and2)to identify areas in which research and clinical trials are urgently needed. The conference and the guideline process are in part based on an important and carefully conducted survey, the first global survey of 950 women living with metastatic breast cancer in nine countries (Bridge survey).2Mayer M, Hunis A, Oratz R et al. Evaluating the needs of women living with metastatic breast cancer: a global survey. In: Presented at the 11th Bi-Annual Conference on Primary Therapy of Early Breast. Vol March 11–14; 2009.Google Scholar, 3Fallowfield L, Hunis A, Oratz R et al. Identifying barriers preventing clinical trial enrollment: results of a global survey of patients with metastatic breast cancer. In: Proceedings of the 100th Annual Meeting of the American Association for cancer research (AACR), Denver, Colorado. Vol April 18–22, 2009: 2009.Google Scholar This survey identified major needs of women with metastatic disease as well as describing sources of information resources, psycho-social support and access to clinical trials. Public interactive sessions were held during three consecutive European Breast Cancer Conferences (EBCC), followed by the establishment of the First International Consensus Guidelines Conference on ABC (ABC 1) held in November 2011. The manuscript recently published in The Breast,1Cardoso F. Costa A. Norton L. et al.1st International consensus guidelines for advanced breast cancer (ABC 1).The Breast. 2012; 21: 242-252Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar summarizes the guidelines developed at ABC 1. The guidelines are nicely laid out with a clear demonstration of the levels of evidence supporting each statement, linked with supporting references and highlighting areas where research efforts are urgently needed. The guidelines were built on the previous work of the ESO ABC Taskforce and on subsequent clinical data using a coordinated effort with the European Society of Medical Oncology (ESMO) guideline methodology. A final set of guidelines was presented, discussed and voted on during the consensus session of ABC 1. There was considerable agreement on virtually all guidelines amongst the 33 breast cancer experts from different countries at ABC 1, who represented a wide variety of health professionals, advocates, and survivors. The guidelines stress the importance of the use of multidisciplinary teams and the use of defined and established specialized breast units.4EUSOMA The requirements of a specialist breast unit.Eur J Cancer. 2000; 36: 2288-2293Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar While these units are not available everywhere, the guidelines stress the importance of efforts to provide all patients with metastatic breast cancer with specialized services such as radiation and pain control. The guidelines stress assessment techniques, including careful history taking and physical examination, ongoing history taking, the use of repeat biopsies whenever possible and fastidious general treatment approaches. Assessment of concurrent medical conditions and age are also emphasized and pain management approaches outlined. The use of appropriate pathology-based selection of endocrine therapy whenever possible and the optimal use of HER2 targeted therapies, again based on best pathologic determinations and availability are well delineated. The use of sequential monotherapeutic chemotherapy on an ongoing basis in order to provide improved overall survival, but adjusted according to patient choice, toxicities and individual situations, is well described. Treatment guidelines concerning bone protection with bisphosphonates or denosumab and the use of radiation therapy for control of bone lesions are also appropriately stressed. The excellent discussion of the role of treatment for brain metastases is also timely. With radiosurgery and surgery now used more commonly, patients with metastatic CNS disease can live for several years after this diagnosis while treatment with whole brain radiation with its risks of neurocognitive effects, can sometimes be avoided until later. A strong emphasis on supportive and palliative care and guidelines for the treatment of male breast cancer are also included. The reinforcement provided by advocates groups in the development of these consensus guidelines represents an important advance in ABC setting. Advocates are driving more attention to this disease as a public health priority, as well as to the need of funding and the use of meaningful of clinical trials endpoints such as quality-of-life measures and patient-reported outcomes. These guidelines represent not only a solid achievement in themselves but also an important step on the path forward in treating advanced breast cancer. A second meeting will be held in September of 2013. Between now and then, the guidelines will be further refined and updated with new information and new levels of evidence. Innovative aspects of this ongoing process include the use of not only physician specialists of all types as well as nurses, pharmacists, and other health professionals, but of patients and advocates from across the spectrum. It is also important to point out that the MBC Advocacy Working Group as well as the Bridge survey are land-mark initiatives that have been sponsored by the pharmaceutical industry not by a governmental or an academic body. This represents good will on the part of industry to fill a patient need in a setting where direct financial gains are not available. All in all, the journey which began with the formation of the ABC Taskforce in 2005, continued through the Bridge Summary and the public and interactive sessions that followed, and included the first ABC 1 meeting and production from it of these guidelines, represents strong and innovative progress in our approach to the care of men and women with metastatic breast cancer. That follow-up meetings and ongoing work will continue this process is both impressive and inspiring.

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