Nice St Paul Breast Cancer Guidelines : 2013 5 topics : - Axillary nodal exploration - Tumor Proliferation - Treatment resistance - Neoadjuvant treatments - T1ab tumors

Breast Cancer Guidelines and Axillary nodal

exploration

Emmanuel BARRANGER, Jean-Marc CLASSE, Marie Mélanie DAUPLAT, Gilles HOUVENAEGHEL, Alain TOLEDANO

1.  Must  we  perform  an  addi3onal  axillary  clearance  in  case  of  isolated  tumor  cells  in  the  sen3nel  nodes?.    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

6%

63%

27%

4%

2 -  In  case  of  conserva3ve  surgery,  followed  by  a  RT  and  a  systemic  medical  treatment,  must  we  perform  an  axillary  clearance  in  case  of  1  or  2  micrometasta3c  sen3nel  nodes?  

1 - Yes

2 - No

3 – Too few data

4 – Abstain

25%

48%

21%

6%

3.  In  case  of  conserva3ve  surgery,  followed  by  a  RT  indica3on  and  a  systemic  medical  treatment,  must  we  perform  an  axillary  clearance  in  case  of  1  or  2  macrometasta3c  sen3nel  nodes?    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

63%

8%

22%

6%

7.  Can  we  assess  axillary  lymph  node  involvement  with  sen3nel  nodes  technique  aEer  NACT  (Neoadjuvant  chemotherapy)  in  case  of,  clinical  and  ultrasonographic  N0  tumor?      

1 - Yes

2 – No

3 – Too few data

4 – Abstain

27%

46%

19%

8%

10. Must we recommend an axillary radiotherapy in case of pN1 micrometastases without an additional axillary clearance?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

50%

20%

13%

17%

Breast Cancer Guidelines and tumor

Prolifération

Fabrice ANDRE, Suzette DELALOGE, Jean-Marc GUINEBRETIERE, Thierry PETIT, Jean-Yves PIERGA, Daniel ZARCA

Préambule

Among the tests assessing proliferation we can consider the following ones (IMPAKT group.

! Oncotype Dx™, Mammaprint®, PCR-GG®, PAM50™, TBCI™ et Endopredict®

n Plus an individual marker of the proliferation ! Ki67

2.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  decision  in  HER2  posi3ve  BC,  ≥ pT1c, N+ ou N- ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

2%

94%

0%

4%

3.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  decision  in  a  ≥  pT1c,  HR+,  HER2-­‐,  >  3pN+?    

1 - Yes

2 - No

3 – Too Few data

4 – Abstain

19%

75%

0%

6%

4.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  decision  in  a  ≥  pT1c,  HR+,  HER2-­‐,  1-­‐3  pN+?    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

55%

29%

10%

6%

5.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  indica3on  in  case  of  T1/T2,  G3,  N-­‐,  HR+,  HER2  -­‐?    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

50%

30%

8%

12%

6.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  indica3on  in  case  of  ≥  T1c,  G2,  N-­‐,  HR+,  HER2-­‐  tumor?  

1 - Yes

2 - No

3 – Too few data

4 – Abstain

85%

4%

0%

10%

7.  Are  some  of  these  genomic  signatures  useful  for  an  adjuvant  chemotherapy  indica3on  in  case  of  ≥  T1c,  G1,  N-­‐,  HR+,  HER2-­‐  tumor?    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

39%

49%

4%

8%

8 - For HR+ tumor, for which you have agreed to perform a test , which one(s) seem(s) useful for you to make you opt for an adjuvant chemotherapy?

1 - Oncotype Dx™

2 - Mammaprint®

3 - PCR-GG®

4 - PAM50™

5 - Endopredict®

6 - TBCI™

7 - Ki67

8 – any

78%

24%

12%

12%

27%

2%

90% 0%

Multiple choice Admitted

9 - Is Ki67 sufficent for an adjuvant chemotherapy indication in case of HR+, HER- breast cancer as defined previously?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

29%

45%

20%

6%

Breast Cancer Guidelines and Treatment resistance

Monica ARNEDOS, David AZRIA, Thomas BACHELOT, Mario CAMPONE, Anne VINCENT-SALOMON

1 – In optimal condition, must a single metastasis be systematiquely biopsied?

1 - Yes

2 - No

3 – Too Few Data

4 – Abstain

87%

13%

0%

0%

2 - Beside a single metastasis, are there any setting where a biopsy must be performed systematically?

1 - Yes

2 - No

3 – Too Few Data

4 – Abstain

67%

10%

4%

18%

3 - Can we define the specific evolution criteria and modalities required to opt for the best 1st line metastatic treatment?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

73%

2%

2%

23%

4- If so, which parameter should be considered ?

1 – Free Interval time

2 – Type of adjuvant systemic treatment

3 – Metastatic relapse location

4 – Sub-molecular classes.

5 – Menopausal status

6 – Other

91%

84%

70%

84%

72%

40%

Multiple choice Multiple choice admitted

5 – Can we define a primary resistance to hormonal treatment for an HR+ tumor treated in adjuvant setting?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

53%

23%

11%

13%

6- If so, which of the following parameters should be considered:

Multiple choice admitted

1 – Early relapse : during the first 2 years of adjuvant Hormonotherapy (HT).

2 – Relapse during the adjuvant hormonotherapy

3 – Free Interval time after completion of adjuvant HT

4 – Sub molecular classes.

5 - Other

80%

56%

20%

36%

16%

7– Can we define a secondary resistance to a first line anti hormonal treatment for a metastatic HR+ tumor ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

89%

4%

0%

6%

8- If so, which of the following parameters should be considered :

Choix multiple possible

1 – Duration of disease control due to the antihormonal treatment for < than 3 months 2 - Duration of disease control due to the antihormonal treatment for < than 6 months 3 Duration of disease control due to the antihormonal treatment for < than 12 months 4 – Sub molecular classes

5 - Other

47%

50%

18%

18%

8%

9- Must we consider metastatic site as well as therapeutic response to opt for the best therapeutic strategy ie, chemotherapy or hormonotherapy?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

58%

23%

6%

13%

10- Must a breast cancer metastasis progressing with a non steroidal hormonotherapy, could (should) receive Everolimus + the non steroidal HT in 2nd line treatment?.

1 - Yes

2 - No

3 – Too few data

4 - Abstain

29%

27%

20%

24%

11- What do you advocate in case of a patient HER2 + who is progressing while treated with trastuzumab for a 1rst line?.

1 – To continue with trastuzumab

2 – To substitute trastuzumab for Lapatinib

3 – To combine trastuzumab and Lapatinib

4 - other

45%

8%

38%

10%

12 - In case of an metastatic HER2 + breast cancer patient progressing with trastuzumab, do the metastatic site have an influence on future therapeutic strategies (CNS vs other)?.

1 - Yes

2 - No

3 – Too few data

4 – Abstain

65%

13%

9%

13%

BreastCancer Guidelines and

Neoadjuvant treatment

Luc CEUGNART, Francette ETTORE, Anthony GONÇALVES, Christophe HENNEQUIN, Rémy SALMON

1- Are the following parametters necessarry and sufficient for NAT decision : hystological type, mitotic index, HR status, HER2 status, Ki 67 ?

1 - Yes

2 - Non

3 – Too few data

4 - Abstain

54%

36%

6%

4%

2. When NAT is considered, is an initial surgical consultation essential to assess and explain the surgical options to the patients

1 - Yes

2 - No

3 – Too few data

4 – Abstain

96%

2%

2%

0%

3. Must we propose a systematic, morphologic and functional breast MRI at the begining of NAT, whether conservative surgery is considered

1 - Yes

2 – No

3 – Too few data

4 – Abstain

54%

31%

13%

2%

4. Must we perform a systematic a whole body work up including, TEP TDM at the beginning of NAT?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

27%

60%

10%

2%

5. Must we set up an intratumoral clip at the beginning of any conservative NACT?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

92%

6%

0%

2%

6. Can we consider that some submolecular subtype breast cancer are sufficent to apply a neo adjuvant strategy; a part from the classical indication for conservative surgery or for carcinologic purposes. (T4D) ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

35%

39%

26%

0%

7 – Must we contraindicate a NACT for a postmenopausal HR+; lobular BC; with a low proliferation?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

77%

19%

2%

2%

8.  Can  we  propose  a  NA  hormonotherapy  for  conserva3ve  purposes  for  some  HR+  menopausal  pa3ents  with  a  low  prolifera3on?.    

1 - Yes

2 - No

3 – Too few data

4 – Abstain

60%

9%

20%

11%

9 - In NA setting, regarding the selection of the agents and/or the administration of the products, must the CT medication differ from that of adjuvant setting?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

11%

70%

13%

7%

10 Must  we  include  another  an3HER2  agent  in  combina3on  with  trastuzumab  in  NA  se[ng  for  HER2+  breast  cancer  ?.      

1 - Yes

2 - No

3 – Too few data

4 – Abstain

15%

32%

51%

2%

11. Are the indication and the modalities of post operative RT the same with and without NAT ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

59%

20%

14%

7%

12 - In case of histological partial response, after a complete NACT protocole, must we consider an adjuvant cytotoxic treatment different from the initial NACT. ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

14%

30%

53%

2%

Breast Cancer Guideline and Management of pT1a,b pN0

Yazid BELKACEMI, David COEFFIC, Paul COTTU, Florence DALENC, William JACOT, Magali LACROIX

1 - Must we consider that prognostic and predictive tumor markers of pT1ab breast cancers have the same value than for bulkier tumor?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

83%

12%

5%

0%

2 - For all invasive pT1ab N0 breast cancers cases, can we recommand not to perform any workup?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

78%

17%

5%

0%

3 - Can we define the BC optimal features allowing us to prevent RT in the management of pT1ab N0 breast cancer undergoing a conservative surgery?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

14%

55%

25%

7%

4- Must we perform a systematic boost on the tumoral bed of pT1ab breast cancer undergoing a conservative surgery with a normal fractionated RT ?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

27%

49%

5%

20%

5 - Can we define the optimal tumoral feature of some pT1ab breast cancers with a RT indication, allowing to use specific irradiation techniques of the mammary gland ie, hypofractionated irradiation partial irradiation, Intra Operative radiotherapy (IORT)

1 - Yes

2 - No

3 – Too few data

4 – Abstain

43%

10%

30%

18%

6- Must we propose a chemotherapy for all Triple negative pT1a pN0 invasive ductal carcinoma

1 - Oui

2 - Non

3 - Données insuffisantes

4 - Je m'abstiens

19%

59%

19%

3%

7- Must we propose a chemotherapy for all Triple negative pT1b pN0 invasive ductal carcinoma

1 - Yes

2 - No

3 – Too few data

4 – Abstain

46%

20%

22%

12%

8 - Must we perform an adjuvant treatment combining chemotherapy and Trastuzumab for all T1a, pN0, HR+, HER2 + breast cancer?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

37%

39%

17%

7%

9 – Must we perform an adjuvant treatment combining chemotherapy and Trastuzumab for all pT1b, pN0, HR+, HER2 + breast cancer?

1 - Yes

2 - No

3 – Too few data

4 - Abstain

66%

5%

24%

5%

10- Must we perform an adjuvant treatment combining chemotherapy and Trastuzumab for all pT1a, pN0, HR negative, HER2 + breast cancer?

1 - Oui

2 - Non

3 - Données insuffisantes

4 - Je m'abstiens

45%

14%

34%

7%

11- Must we perform an adjuvant treatment combining chemotherapy and Trastuzumab for all pT1b, pN0, HR negative, HER2 + breast cancer?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

88%

0%

10%

2%

12- Can we perform an adjuvant treatment combining an antihormonal treatment only with trastuzumab for some pT1ab, pN0, HR+, HER2+?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

19%

26%

43%

12%

13- Can adjuvant treatment be avoided for some pT1a pN0, HR +, HER2 negative breast cancers?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

78%

20%

0%

2%

14- Can adjuvant treatment be avoided for some pT1b pN0, HR +, HER2 negative breast cancers?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

50%

40%

5%

5%

15- For T1a, HR +, HER2 negative, can we define the tumoral features able to indicate an adjuvant chemotherapy?

1 - Yes

2 - No

3 – too few data

4 – Abstain

34%

27%

37%

2%

16- For T1b, HR +, HER2 negative, can we define the tumoral features able to indicate an adjuvant chemotherapy?

1 - Yes

2 - No

3 – Too few data

4 – Abstain

45%

13%

33%

10%