METASTATIC BREAST CANCER: RECOMMENDATIONS PROPOSAL FROM THE EUROPEAN SCHOOL OF ONCOLOGY (ESO)- MBC TASK FORCE

Due to a worldwide increase of cancer incidence and a longer life expectancy of patients with metastatic cancer, a rise in the incidence of symptomatic vertebral metastases has been observed. Metastatic spinal disease is one of the most dreaded complications of cancer as it is not only associated with severe pain, but also with paralysis, sensory loss, sexual dysfunction, urinary and fecal incontinency when the neurologic elements are compressed. Rapid diagnosis and treatment have been shown to improve both the quality and length of remaining life. This chapter on vertebral metastases with epidural disease and intramedullary spinal metastases will be discussed in terms of epidemiology, pathophysiology, demographics, clinical presentation, diagnosis, and management. With respect to treatment options, our review will summarize the evolution of conventional palliative radiation to modern stereotactic body radiotherapy for spinal metastases and the surgical evolution from traditional open procedures to minimally invasive spine surgery. Lastly, we will review the most common clinical prediction and decision rules, framework and algorithms, and guidelines that have been developed to guide treatment decision making.

Liver metastases from breast cancer (LMBC) have long been considered as a systemic disease because of the hematological route of dissemination, requiring noncurative management. In fact, despite recent advances in drug therapies personalized to tumor phenotype, the chances of a cure are nil and there is little hope of long-term survivors after nonsurgical management alone. By contrast, there is a growing evidence in the literature for satisfactory long-term results after a combination of chemotherapy and liver resection, with 5-year survival reaching >40% in some series. The surgical management of LMBC is still restricted to carefully selected patients, managed in high-volume hepatobiliary surgery and cancer research centers. Under these conditions, resection can be performed at the price of very limited morbidity and near zero mortality. The best results after the resection of LMBC are obtained after applying selection criteria based on small metastases (<4-5 cm), minor hepatectomy, radical resection (ideally R0, or R1), stable disease (ideally in regression) after neoadjuvant therapy, and a delay between primary and secondary lesions longer than 1 or 2 years (reflecting a favorable oncologic context). The age of the patient, her hormone receptor status, and HER2 overexpression are not strong predictors of survival. The role of radiological alternatives still needs to be defined (radiofrequency, microwave ablation, radioembolization), and these raise questions regarding a reliable pretreatment assessment of tumor spread. Finally, surgical results are based on scarce evidence and need to be confirmed by large-scale studies so that they will be more widely accepted by the medical community.

Until recently, many international guidelines have focussed on the treatment of early-stage breast cancer, with little emphasis on advanced-stage disease. To improve the management of advanced breast cancer (ABC), the European School of Oncology (ESO) established the ABC International Consensus Conference and Guidelines. Delegates from the first conference and additional groups selected by ESO were invited to complete a survey to identify current challenges and barriers associated with optimizing ABC management. 609 Respondents from 78 countries completed the questionnaire. “Lack of clear and applicable management guidelines” and “lack of high-level evidence for treatment options” were identified as key barriers to raising the profile of ABC and treating the disease. The survey also revealed a lack of multidisciplinary treatment, specialized ABC nurses, and routine psychosocial support in clinical practice. Implementing high-quality guidelines could lead to better practice in the management of ABC by encouraging multidisciplinary treatment and patient-support initiatives.

In clinical practice, the surveillance and follow-up of patients with breast cancer (BC) is quite variable. At the 7th European Breast Cancer Conference, the ESO-MBC Task Force convened a series of lectures, followed by open debate, on the use of physical examination, imaging, and laboratory tests in patients with early-stage BC, and for restaging evaluations and follow-up among patients with MBC. Based on the available data, the Task Force recommends against intensive, routine radiologic or blood-based surveillance (with the exception of mammography) in patients with early-stage BC. As systemic therapies for MBC continue to improve, this question might be re-visited in the context of a carefully controlled clinical trial in specific BC subtypes. For patients with MBC, response to therapy should generally be assessed 2–3 months after initiation of treatment, and thereafter every 2–4 months for endocrine therapy or every 2–4 cycles for chemotherapy, depending on the dynamics of the disease, the location and extent of metastatic involvement, and type of treatment. Additional testing should be performed irrespective of the planned intervals if progression of disease is suspected (e.g. in the case of specific symptoms). Use of tumor markers is not recommended for surveillance of early-stage patients, but may be helpful in monitoring response to therapy in patients with metastatic disease. However, change in tumor markers alone should not be used for decision-making. Moving forward, enhanced efforts to document quality of life over time should be made in order to more fully evaluate the risk/benefit ratio of available options.