Individualizing Treatment
Posted 6/22/2009
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As many of you know, science is moving in the direction of better individualized treatments for cancer patients. An example of how this long been true in the treatment of breast cancer is the distinction between tumors that are ER positive (and therefore respond to hormonal therapies) and those that are ER negative (and would not be responsive to such treatments). More recent distinctions have included the classification of breast cancer tumors as her2 positive or her2negative (indicating whether or not herceptin would be a helpful therapy).
At the annual expert consensus meeting in St. Gallen, Switzerland, a position statement was developed that describes this growing model of designing treatment for early stage breast cancer. Treatment decisions are no longer made solely on the basis of hormonal statue (ER/PR positive or negative) or whether or not there are positive lymph nodes or on the size of the primary tumor in the breast. Instead, a number of pathological factors are considered and, sometimes, the genetic composition of a tumor is also explored.
Here is a summary of that statement:
HOUSTON, June 17 -- In an international consensus statement described as practice-changing, new treatment guidelines for early stage breast cancer call for use of systemic therapies on the basis of individual tumor characteristics.
Treatment decisions should focus on the scientific justification for using endocrine therapy, anti- HER2 treatment, and chemotherapy, authors of the 2009 St Gallen International Expert Consensus concluded in guidelines published online in Annals of Oncology.
Though recognizing the heterogeneous nature of breast cancer, the consensus recommendations call for development of a personalized treatment plan for each patient.
The guidelines include a new treatment algorithm based on advances in knowledge about how to match therapy with tumor characteristics to achieve the best outcomes.
"Because these decisions are based on quite separate criteria, previous attempts to produce a single-risk categorization and a separate therapy recommendation are no longer considered appropriate," the authors said. In a prepared statement, panel member Richard Gelber, MD, of Harvard and Dana-Farber Cancer Institute in Boston, said the consensus "further refines the treatment algorithm by identifying 'thresholds for indication' of each type of systemic treatment modality based on criteria specific to each modality.
"We expect the refined algorithm to change clinical practice because it clarifies the indications for each treatment modality available today." Knowing the specific tumor characteristics is essential for deciding which treatment or combination offers a patient the best chance for success. Consistent with that approach to decision making, the panel set forth some general principles for treatment selection:
Adjuvant endocrine therapy is recommended for most patients with any detectable level of estrogen receptor (ER). Anti-HER2 therapy, currently limited to trastuzumab (Herceptin), is recommended for almost all patients with HER2-positive disease.
Reflecting the more complicated decision-making process surrounding adjuvant chemotherapy, the consensus panel said chemotherapy should be the mainstay of treatment for patients with triple-negative breast cancer. For HER2-positive
patients, clinical trial evidence for trastuzumab is limited to its use with or after chemotherapy. Less consensus exists about its use in patients with estrogen receptor (ER)-positive, HER2-negative disease.
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