Breast cancer
Also known as: breast cancer screening · mammography
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Selection of Optimal Adjuvant Chemotherapy and Targeted Therapy for Early Breast Cancer: ASCO Guideline Update
ASCO · 2021 · 2021 (CDK4/6 rapid recommendation update 2024)
The American Society of Clinical Oncology's guidance on choosing drug therapy after surgery for breast cancer that has not spread beyond the breast and nearby nodes. It addresses what to add when cancer remains at surgery despite pre-operative treatment, how HER2-targeted treatment should be given, and which patients benefit from adding a CDK4/6 inhibitor to endocrine therapy. A 2024 rapid update revised the CDK4/6 recommendations in light of new trial data.
- For HER2-negative disease with invasive cancer still present at surgery after anthracycline- and taxane-based pre-operative treatment, additional adjuvant capecitabine may be offered. source
- For HER2-positive disease with residual invasive cancer after pre-operative chemotherapy plus HER2-targeted treatment, adjuvant T-DM1 should be offered unless the disease progresses or toxicity is unmanageable. source
- Any approved trastuzumab formulation, including biosimilars and the subcutaneous product, is considered acceptable. source
- A 2024 rapid recommendation update revised the guidance on adding CDK4/6 inhibitors to adjuvant endocrine therapy for higher-risk hormone-receptor-positive, HER2-negative disease. source
Early breast cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up
European Society for Medical Oncology (ESMO) · 2024
The current ESMO guideline for early (non-metastatic) breast cancer, covering diagnosis, staging, risk assessment, systemic and local treatment, follow-up and specific clinical situations, together with the patient perspective. ESMO maintains separate documents for metastatic disease.
- Covers diagnosis, staging, risk assessment, treatment and follow-up for early breast cancer. source
- Recommendations are accompanied by ESMO-MCBS and ESCAT scores where applicable. source
- Published in Annals of Oncology, volume 35, pages 159-182 (February 2024, online December 2023), lead author S. Loibl. source
US vs EU key differences
- The documents are not the same size of object: the ESMO guideline spans diagnosis, staging, surgery, radiotherapy, systemic therapy and follow-up for early breast cancer, while the ASCO guideline is a narrow update on selecting adjuvant chemotherapy and adjuvant targeted therapy only. Comparisons are therefore only meaningful on the systemic-therapy questions they share. source
- The two converge on post-neoadjuvant HER2-positive disease: both endorse up to 14 cycles of adjuvant trastuzumab emtansine (T-DM1) for patients left with residual invasive disease after neoadjuvant chemotherapy plus HER2-targeted therapy. source
- Three years of new evidence separate them: ESMO 2024 recommends one year of adjuvant olaparib for germline BRCA1/2 carriers, two years of abemaciclib added to endocrine therapy in high-risk hormone-receptor-positive disease, and pembrolizumab with chemotherapy in triple-negative disease, none of which feature in the 2021 ASCO update whose sole new recommendation was adjuvant T-DM1. source
- ESMO resolves a sequencing conflict the ASCO update never faced: when a patient qualifies for both adjuvant olaparib and adjuvant abemaciclib, olaparib is preferred for its larger and statistically significant overall survival benefit, the two should not be combined because of overlapping toxicity, and if used sequentially olaparib comes first. source
- ESMO makes risk assessment for hormone-receptor-positive disease explicitly multi-modal, combining clinicopathological factors, gene expression assays and endocrine response assessment to decide who needs chemotherapy, and requires a CPS+EG score of at least 3 for olaparib in hormone-receptor-positive tumours without pathological complete response. source
What changed recently
- EU2019 → 20242024-02-01
ESMO states this edition supersedes the 2019 early breast cancer guideline. It gives gene expression assays and endocrine response assessment a formal role in deciding whether adjuvant chemotherapy is needed when clinicopathological factors are equivocal, and it restricts baseline imaging for distant metastases to stage IIB or higher, high-recurrence-risk or symptomatic patients rather than routine staging.
source ↗curation confidence 90% - US2018 focused update → 2021 (CDK4/6 rapid recommendation update 2024)2021-01-01
The 2021 update revised the 2018 focused update mainly on the strength of the KATHERINE trial, adding adjuvant ado-trastuzumab emtansine for HER2-positive patients left with residual invasive disease after neoadjuvant chemotherapy plus HER2-directed therapy instead of continuing trastuzumab. A 2024 rapid recommendation update subsequently folded in adjuvant CDK4/6 inhibitors for high-risk hormone receptor-positive disease.
source ↗curation confidence 90%
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