Recommendations proposal from the European School of Oncology(ESO)–MBC Task Force
Treatment of metastatic breast cancer is consid-
providing general recommendations regarding MBC
ered to be an art. Contrary to the early breast
management. This list of statements was discussed
cancer setting, where level 1 evidence exists for
by a panel of experts with active interaction with
the majority of treatment options, for metastatic
the audience in a plenary session during EBCC-5,
breast cancer there are few approved standards of
and received with great interest. This short pub-
care, particularly after first-line treatment. Con-
lication presents these statements. The second
sequently, while several international guidelines
step will be the development and publication, in a
exist and are used worldwide for adjuvant therapy,
peer-reviewed form, of more detailed guidelines
international guidelines on metastatic breast can-
cer treatment are rare and not usually adhered to
supporting references and documentation.
by the majority of treating oncologists.
Advances in breast cancer care and new drug
development over the last few decades have beenimpressive and currently, fortunately, a wide array
of options exists for the management of metastaticbreast cancer. Notwithstanding these improve-
(1) The management of metastatic breast cancer
ments, many questions remain unanswered or are
(MBC) is complex; therefore, involvement of
controversial, particularly since it is still an incur-
all appropriate specialties in a multi/inter-
able disease where the main goal is to improve the
disciplinary team (medical, radiation, surgical
quality and, whenever possible, increase the
and imaging oncologists, palliative care, psy-
quantity of life. Therefore, the treatment of this
cho-social, among others) is crucial.
disease is remarkably different among countries,
(2) From the first diagnosis of MBC, patients
centres and even among individual oncologists.
should be offered personalised appropriate
With the ever-increasing costs of new treatments,
psychosocial, supportive, and symptom-re-
biological markers, and supportive and palliative
lated interventions as a routine part of their
care measures, a wise and balanced use of
(3) Following thorough assessment and confirma-
Based on these facts, the European School of
tion of MBC, the realistic treatment goals must
Oncology, in collaboration with the European
be specified and discussed. Patients and family
Breast Cancer Conference (EBCC) organisers, has
members should be invited to participate in all
created a task force with the aim of developing
international guidelines for the management of
(4) A small but very important subset of MBC
metastatic breast cancer. Acknowledging the diffi-
patients, for example, those with a solitary
culty of the task, it was decided to launch the
metastatic lesion, can achieve complete re-
process in two steps. The first, which took place at
mission and a long survival. For these selected
EBCC-5 in Nice in March 2006, was to prepare a list
of 12 statements highlighting the main issues and
disciplinary approach should be considered.
A clinical trial addressing this specific situation
(9) The choice between sequential use of single
cytotoxic drugs and combination chemother-
(5) Minimal staging work-up for MBC includes a
apy should be taken after consideration of the
history and physical examination, complete
factors mentioned in paragraph 6, with great-
haematology and biochemistry, and imaging of
the chest, abdomen and bone. The clinical
significant response and on quality of life. For
value of tumour markers is not well estab-
the majority of patients, overall survival
lished for diagnosis or follow-up; however,
outcome from sequential use of single cyto-
their use as an aid to evaluate response to
toxic drugs seems to be equivalent to that
treatment, particularly in patients with non-
after combination chemotherapy. Duration of
each regimen and number of regimens should
(6) Treatment choice should take into account:
be tailored to each individual patient.
endocrine responsiveness, HER-2 status, me-
(10) There are few proven standards of care in MBC
nopausal status, disease-free interval, pre-
management. Therefore, inclusion of patients
vious therapies and response obtained, tumour
in well-designed, independent, prospective
burden (defined as number and site of metas-
randomised trials must be a priority whenever
tases), biological age and co-morbidities (in-
available. Every proposed option must have
status, need for rapid disease/symptom con-
trol, socio-economic and psychological fac-
(11) The medical community is aware of the
problems raised by the cost of MBC treatment.
therapies in the patient’s country (this list is
instances, but the patient’s well-being, length
(7) Endocrine therapy is the preferred option for
and quality of life must always be the main
hormonal receptor-positive disease, unless
there is concern or proof of endocrine resis-
(12) Formal (not just informal) quality of life
tance. The optimal first-line hormonal treat-
assessments provide useful information and
aromatase inhibitor; however, tamoxifen re-
information should be integrated with that
mains a viable option. For pre-menopausal
from clinic assessments to allow management
decisions on initiating, changing, or stopping
suppression/ablation is the first choice except
post-aromatase inhibitor treatment is uncer-tain. Maintenance of hormonal treatment
after chemotherapy is not established, but isreasonable.
Co-ordinators: F. Cardoso, BE E.P. Winer, US
L. Fallowfield, UK M. Namer, FR O. Pagani,
(8) Trastuzumab should be offered early to all
CH S. Rodenhuis, NL E. Senkus-Konefka, PL
HER-2-positive MBC patients, after failure of
endocrine therapy if this is appropriate. Trastuzumab in combination with endocrinetherapy is under evaluation in clinical trialsand cannot yet be considered as standard.
Additional experts present at round table
Currently, the optimal management of pa-tients progressing on trastuzumab is uncertain
M. Piccart, BE J. Jassem, PL K. Albain, US
and active research is ongoing in this area.
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