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Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2011 Update in Breast Cancer: Coverage of the American Society of Clinical Oncology (ASCO) Annual Meeting CME/CE Certified Course. The course is under the direction of Kevin Fox, MD, medical director of the Rena Rowan Breast Center. This is the last of four posts about the latest findings in treating breast cancer.

More News on Aromatase Inhibitors (AIs)
A group of bone health-related studies (Abstracts 516, 517, 518) presented at the 2011 ASCO conference provided some good news on bone loss. The studies showed that postmenopausal breast cancer patients undergoing endocrine therapy (aromatase inhibitors) do not experience an increase in their total number of fractures, despite having some level of bone loss.

Over a period of approximately six years, 5 percent of patients receiving aromatase inhibitors (AIs) suffered fragility fractures, the same percentage as occurred in the control group. Studies also show that exemestane may result in less bone loss than other AIs.

A third set of AI studies (Abstracts 522,523 525) strengthened the data supporting the proposition that women who experience endocrine-related symptoms, specifically arthralgia and bone pain, while taking AIs do have improved treatment efficacy.

Regional vs. Whole Breast Irradiation for Node-Positive Cancer
The controversy regarding the optimal treatment approach for breast cancer with one to three positive nodes has existed for some time. Current treatment guidelines call for regional lymph node irradiation (RNI) for all patients with four or more positive nodes, but have been less clear about the role of RNI in cases involving one to three nodes.

Another trial highlighted at the ACO conference, NCIC-CTG MA.20, bolsters the view that all node-positive breast cancer patients should be considered for RNI.

In this large, intergroup trial, women with positive nodes or high-risk node negative breast cancer were treated with breast-conserving surgery. They were then randomized to receive either standard whole breast irradiation (WBI) or WBI plus RNI. The study demonstrated a clear advantage for the WBI plus RNI group for five year overall and disease-free survival. They did experience modestly increased toxicity, mostly attributable to a slight increase in grade II lymphedema.

Focus on Neoadjuvant Therapy for HER2-Positive Breast Cancer
Neoadjuvant therapy, or therapy that is given before primary cancer treatment, is becoming a standard way to study new approaches to treating breast cancer. Angela DiMichele, MD, assistant professor of medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, noted the emphasis on neoadjuvant therapy at the ASCO meeting, citing several studies for women with HER2-positive breast cancer, a group for which there is a growing number of treatment options.

The first (abstracts 505, 507) combined lapatinib and trastuzamab in a neoadjuvant setting without chemotherapy for women with HER2-postive tumors >3cms or >2cms with palpable nodes. The results were positive with an overall pCR of 28 percent and a 40 percent pCR in ER- negative patients and strengthened the evidence for the dual receptor blockade as the new standard of therapy for HER2-positive tumors. The study did have an 8 percent drop out rate resulting from toxicity, primarily diarrhea and acne form rash.

The other studies (abstracts 531, 532) looked at the results of adding chemotherapy to the dual receptor blockade. The first demonstrated a clear advantage to lapatinib and trastuzamab with anthracycline-taxane therapy in terms of pCR, but left unanswered issues as to whether the increased toxicity with chemotherapy is worth the risk and whether the pCR will translate into long-term survival.

Triple-Negative Breast Cancer
While the options for HER2-postive patients continue to expand and improve, the need remains to discover more effective therapies for the 15 percent of patients diagnosed with triple negative breast cancer (TNBC). While considerable attention was focused on TNBC at ASCO 2011, the meeting did not yield significant progress for women with this disease.

Several trials offered data suggesting that basal subtypes of breast cancer might be sensitive to platinum, but much more information is needed to clarify which subgroups of patients and under which circumstances will benefit from this therapy (Abstract 1015). Similar issues apply to the use of agents targeted to the mTOR and PI3K pathways (abstract 1016). The conclusion: For TNBC, a commitment to larger, well-designed trials with integrated, adequately-powered biomarker assessment are needed.

Abstracts can be found on the 2011 ASCO meeting website.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

Are you at risk for breast cancer? Attend Penn Women’s Cancer Conference – Focus on Your Risk of Breast/Ovarian Cancer

Are you a breast cancer survivor? Attend the Penn Women’s Cancer Conference – Life after Breast Cancer

Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2011 Update in Breast Cancer: Coverage of the American Society of Clinical Oncology (ASCO) Annual Meeting CME/CE Certified Course. The course is under the direction of Kevin Fox, MD, medical director of the Rena Rowan Breast Center. This is the third of four posts about the latest findings in treating breast cancer.

BMI and Cancer Outcomes
In recent years, the belief that obese breast cancer patients have worse outcomes has become somewhat entrenched in the cancer community. A North American Breast Cancer Group study presented in 2010 appeared to be confirmed those findings. But just one year later, data presented at ASCO 2011 data (abstracts 513, 514, 515), appears to contradict that belief.

Angela DeMichele, MD, associate professor of medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, said the combined analysis of five National Cancer Institute studies demonstrate no compelling evidence that obesity, a body mass index (BMI) of 30 or more, compromises breast cancer survival. The studies also show BMI does not affect estrone (the estrogen left after menopause, made primarily by body fat) levels in postmenopausal women.

Despite the discrepancy in the findings, Dr. DeMichele reinforced the need to encourage obese women to lose weight and provide active support to women undergoing hormonal treatment to help them avoid weight gain.

Exemestane Yields Impressive Results in Prevention Study
One of the most noted studies at this year's ASCO meeting was the MAP3 trial (abstract 504), which presented persuasive evidence that the aromatase inhibitor exemestane, has a significant effect in preventing invasive breast cancer in medium to high risk postmenopausal women. The study, released simultaneously in the New England Journal of Medicine, represents a "huge victory for chemoprevention," in the words of the Angela Bradbury, MD, who presented the study at the ASCO meeting.

In this large, multinational study, women who received exemestane had a 65 percent reduction in invasive breast cancer. This is a superior result to the 50 percent reduction seen in studies utilizing tamoxifen and raloxifen.

Over a three-year period, exemestane reduced the incidence of ductal carcinoma in situ and other precancerous conditions, and appeared to reduce the incidence of more aggressive breast cancers in those women who did develop the disease. In addition, the study found that the side effects; hot flashes, insomnia, and arthralgia; were not excessive and generally well tolerated by the study participants. Serious toxicities including fractures, other cancer, osteoporosis and cardiovascular events were not seen in the study participants.

While the MAP3 results are without question important and exciting, some experts question whether healthy women will take a drug that is associated with a spectrum of menopausal type symptoms, even to achieve an important goal of reducing invasive breast cancer. The answer may depend on a variety of factors including:

• Level of individual risk
• Age
• Overall health
• Conversations between women and their doctors as they become aware of this new study and its implications for preventing the second leading cause of cancer deaths in women

Abstracts can be found on the 2011 ASCO meeting website.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

Are you at risk for breast cancer? Attend Penn Women’s Cancer Conference – Focus on Your Risk of Breast/Ovarian Cancer

Are you a breast cancer survivor? Attend the Penn Women’s Cancer Conference – Life after Breast Cancer

Coming up next, The Value of Adjuvant and Neoadjuvant Therapy.

Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2011 Update in Breast Cancer: Coverage of the American Society of Clinical Oncology (ASCO) Annual Meeting CME/CE Certified Course. The course is under the direction of Kevin Fox, MD, medical director of the Rena Rowan Breast Center. This is the second of four posts about the latest findings in treating breast cancer. 

One of the larger trends in cancer treatment, especially breast cancer treatment, is the increasing ability to identify biologic subtypes of the disease and the need for better prognostic biomarkers, or biomarkers that provide information regarding outcome without regard for therapy.

Angela DeMichele, MD, MSCE

At the 2011 ASCO conference, Angela DiMichele, MD, MSCE, assistant professor of medicine and epidemiology at the Perelman School of Medicine at the University of Pennsylvania, talked about the important role biology plays in identifying these markers. As co-program leader of the Abramson Cancer Center's National Cancer Institute (NCI)-approved breast cancer program, she discussed one such marker, Ki-67, and intrinsic genetic subtypes.

Two studies (Abstracts 500 and 501) provide support for the validity of Ki-67 as a means of identifying highly proliferative tumors and those that are more likely to respond to specific chemotherapy regimens. Ki-67 is a cancer antigen that is found in growing, dividing cells but is absent in the resting phase of cell growth. This characteristic makes Ki-67 a good tumor marker. This test is done on a sample of tumor tissue, to help predict your prognosis.

Many studies have been done to determine Ki-67's value as a tumor marker test. Researchers agree that high levels of Ki-67 indicate an aggressive tumor and predict a poor prognosis and tumors that tested positive with high levels of Ki-67, have a higher risk of recurrence.

Perhaps more intriguing is the emergence of intrinsic subtypes of breast cancer. Gene expression studies have identified several distinct breast cancer subtypes. The value of this information is less clear, but understanding the specific biologic characteristics that influence these subtypes may help determine which patients will respond to which therapies.

Cancer researchers now understand that breast cancer is a spectrum of diseases, ranging from those that are more endocrine driven to those that are more chemosensitive. These findings reinforce the need for accurate molecular profiling for all breast cancer patients.

OncotypeDX has become a standard means for molecular profiling and guiding breast cancer treatment decisions, but another, potentially even more comprehensive tool is on the horizon. PAM-50 screens for 50 genes and is potentially more sensitive, but is not yet clinically available. Further studies are needed to validate its use.

Abstracts can be found on the 2011 ASCO meeting website.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

Are you at risk for breast cancer? Attend Penn Women’s Cancer Conference – Focus on Your Risk of Breast/Ovarian Cancer

Are you a breast cancer survivor? Attend the Penn Women’s Cancer Conference – Life after Breast Cancer

Coming up next, How Weight and Hormones Affect Breast Cancer Outcomes.

Christine Wilson, cancer survivor, shares her experiences from the Abramson Cancer Center’s 2011 Update in Breast Cancer: Coverage of the American Society of Clinical Oncology (ASCO) Annual Meeting CME/CE Certified Course. The course is under the direction of Kevin Fox, MD, medical director of the Rena Rowan Breast Center. This is the first of four posts about the latest findings in treating breast cancer.

The summary of the latest news in breast cancer treatment was delivered in rapid-fire style at the Abramson Cancer Center’s 2011 Update in Breast Cancer ASCO summary course. Unfortunately, many of those attending the annual conference thought the news was "not as exciting as last year," because of the lack of any single, major breakthrough.

At the 2010 conference, Penn cancer researchers highlighted the promising results of targeted immunotherapy in treating metastatic breast cancer.

While there may have been no single big story, significant data were presented across the full platform of breast cancer-related topics: from prevention to neoadjuvant therapy and managing metastatic disease. Major emphasis was placed on improved understanding of the biology of breast cancer and the development of more targeted therapies tailored to match the specific genetic profiles of patients.

From the Headlines: FDA Approval for Bevacizumab

David M. Mintzer, MD

One issue that has been in the headlines during the past months is the status of FDA approval of bevacizumab (Avastin®) for first-line of treatment of HER2-negative metastatic breast cancer in combination with paclitaxel.  Bevacuzumab received fast track approval in 2008. Subsequent studies, including those presented at ASCO 2011, demonstrated modest improvements in progression-free survival, but none in overall survival or improvement in disease-related symptoms.  The down sides of the drug are its toxicity and high costs of administration.

Just hours after the update concluded, the Oncologic Drugs Advisory Committee voted 6-0 to withdraw FDA approval for bevacizumab for treating HER2-negative metastatic breast cancer. While the committee vote was unanimous, the hearing itself was marked by emotional pleas from breast cancer patients who believe they are benefitting from bevacizumab treatment.   The recommendation is not binding and a final decision is expected in September. It also does not affect insurance coverage or availability at this time, or the drug's approval for other cancer types.

"We know this drug has activity in some women," said David Mintzer, MD, clinical associate professor and chief of hematology/oncology, Pennsylvania Hospital. "We have all seen it and we know that activity stops when you stop giving the drug, but we just know now how to predict which women will get that benefit."

Abstracts can be found on the 2011 ASCO meeting website.

Learn more about breast cancer treatment at Penn’s Abramson Cancer Center.

Are you at risk for breast cancer? Attend Penn Women’s Cancer Conference – Focus on Your Risk of Breast/Ovarian Cancer

Are you a breast cancer survivor? Attend the Penn Women’s Cancer Conference – Life after Breast Cancer 

Coming up next, Understanding the Biology of Breast Cancer.