Tracks 1-17

Track 1 Adjuvant endocrine therapy for pre-and postmenopausal patients Track 2 Extended adjuvant endocrine therapy beyond five years Track 3 Carryover antitumor effect with anastrozole in long-term follow-up from the ATAC trial Track 4 Long-term safety data from the ATAC trial Track 5 Changing landscape in the care of patients receiving adjuvant endocrine therapy Track 6 Implications of the long natural history of hormone receptor-positive breast cancer Track 7 Delayed, extended treatment with aromatase inhibitors after completion of adjuvant tamoxifen Track 8 Assessment of women who develop chemotherapy-or age-related menopause Track 9 Hormone receptor positivity and benefit from adjuvant chemotherapy Track 10 Potential value of the Oncotype DX assay in providing quantitative assessment of ER and HER2 Track 11 Clinical use of the Oncotype DX assay Track 12 Emerging data with the Oncotype DX assay for patients with hormone receptor-positive, node-positive early breast cancer Track 13 Molecular profiling with the MammaPrint® assay Track 14 Overview of benefit from adjuvant trastuzumab in HER2-positive breast cancer Track 15 Guidelines and quality control for the assessment of HER2 status Track 16 Cardiotoxicity associated with chemotherapy and trastuzumab Track 17 Treatment algorithm for node-negative, HER2-positive tumors

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Tracks 3-4

DR LOVE: Where are we right now in terms of the risks and benefits of aromatase inhibitors for postmenopausal women with breast cancer?

DR CARLSON: The 100-month follow-up of the ATAC trial was one of the most important abstracts presented at San Antonio. The results were encouraging and reassuring. From the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) analysis, we know that the benefits of tamoxifen, in terms of risk reduction for recurrence and death, persist well beyond the period of actual tamoxifen administration (EBCTCG 2005). Some were concerned that this might not be the case with the aromatase inhibitors — that you might win the short game but lose the long game.

The efficacy data from the ATAC trial suggest substantial benefit from anastrozole beyond the five years of actual therapy (ATAC Trialists’ Group 2008; [3.1]). The long-term differences were larger in the ATAC trial than in the EBCTCG analysis of the tamoxifen carryover effect. It’s an indirect comparison, so we have to be cautious, but it is reassuring to observe sustained benefits from anastrozole after treatment is completed.

The toxicity data were also reassuring. No unexpected toxicities, especially bone events, were recorded on long-term follow-up (ATAC Trialists’ Group 2008; [3.1]).

Patients received the initial five years of anastrazole or tamoxifen, and in the subsequent five years, the fracture rates for the women treated with tamoxifen and those treated with anastrozole were superimposable.

DR LOVE: We forget that these patients did not receive bone monitoring and were not administered bisphosphonate therapy. Now that’s part of clinical practice.

DR CARLSON: One of the possible explanations for the fracture curves coming together with the extended follow-up in the ATAC trial is that we have learned that you need to evaluate bone health. Women in the aromatase inhibitor arm may have had their bones assessed and may have received an off-protocol intervention.

DR LOVE: That’s an interesting thought. Another important finding involved the incidence of endometrial cancer during years five through nine: One case versus 12 cases in the anastrozole and tamoxifen arms, respectively (ATAC Trialists’ Group 2008). The presenters posed the question of whether the absence of tamoxifen increases the risk or whether anastrozole has a preventive effect on endometrial cancer, which doesn’t seem that far fetched. What are your thoughts on this?

DR CARLSON: It’s hard to sort out from the data we have, but one would surmise from those numbers that it’s a little of both.

Track 11

DR LOVE: Can you describe how the Oncotype DX assay has influenced your practice?

DR CARLSON: In my practice, I consider using it for women with ER-positive, HER2-negative, lymph node-negative disease, especially in situations in which the woman is reluctant to consider chemotherapy and when the result of the assay would make a difference to her or to me in terms of the confidence with which we approach the therapy.

Women with T1A and probably T1B tumors fare well regardless of what the biomarkers show. It’s for the women who have the T1C, the 1-to 2-cm or even the 3-cm node-negative tumors, that we hope these newer biological systems will be helpful.

Track 14

DR LOVE: Can you summarize what’s happened recently in terms of anti-HER2 therapy for patients with HER2-positive tumors?

DR CARLSON: We have seen a tremendous paradigm shift in how we approach HER2-positive breast cancer, especially in the adjuvant setting. We now have six or seven major randomized trials evaluating combination chemotherapy with or without trastuzumab in the adjuvant setting. Those studies, with the exception of one that was recently reported, are remarkably consistent in the finding that the addition of trastuzumab decreases the risk of recurrence by about 50 percent and decreases the risk of death from breast cancer by about 35 percent (Smith 2007; Slamon 2006; Perez 2007; Viani 2007; [3.2]).

Those are tremendous risk reductions, the types we see with endocrine therapy in hormone receptor-positive breast cancer. They have resulted in the rapid adoption of trastuzumab-containing adjuvant regimens in HER2-overexpressed breast cancer.

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INTERVIEWS

Neil Love, MD
Editor

Monica Morrow, MD
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Ian E Smith, MD
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Robert W Carlson, MD
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Soonmyung Paik, MD
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Breast Cancer Update
for Surgeons:
A CME Audio Series and Activity

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