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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