Den 23. oktober gikk Tema Mamma Oslo av stabelen for andre gang. Møtet organiseres i samarbeid mellom seks legemiddelfirma (Astra Zeneca, GlaxoSmithKline, Novartis,
Pierre Fabre, Roche, Takeda Nycomed) og brystkreft-miljøet i Oslo.
Av Stephanie Geisler
Møtet tar sikte på å samle alle som er involvert i håndtering av brystkreftpasienter til et tverrfaglig møte av høy faglig kvalitet. Denne gangen var møtet fullbooket med over 80 deltagere og til og med flere på ventelisten. I publikumet satt det patologer, onkologer, kirurger, radiologer, sykepleiere – LIS og overleger side om side og lot seg fascinere av den samlede kompetansen – blant foredragsholderne – og tilskuerne.
Programkomiteen hadde lykkes i å få 5 kjente internasjonale foredragsholdere til å stille opp. Vi har mottatt oppsummeringer fra tre av foredragene som er gjengitt lengre nede.
Martine Piccart
Martine Piccart, brystkreft onkologiens ”supernova” som Erik Wist kalte henne i sin innledning, åpnet med et glitrende foredrag om HER2-positiv brystkreft. Hun påpekte viktigheten av immunsystemet for respons på Herceptin behandling og ga oss innblikk i betydningen av tidlig responsevaluering blant annet med FDG-PET av lokalavansert brystkreft under neoadjuvant behandling.
Robert Coleman fra London som er en av de fremste innen bifosfonater og deres effekt på skjelettet og kreftceller, gikk gjennom de siste årenes publikasjoner og deres betydning for gjeldende behandlingsanbefalinger. Han påpekte særlig nytten av bifosfonatbehandling til postmenopausale kvinner med brystkreft med bakgrunn i at flere studier har vist signifikant reduksjon i brystkreftrelatert død, noe som også gjenspeiles i NBCG sine gjeldende anbefalinger.
Etter en kort pause fortsatte Michael Dixon fra Edinburgh med å belyse onkoplastisk brystkreft behandling. Han krydret foredraget sitt med morsomme flimklipp og la inn et godt ord for brystbevarende kirurgi (BCS) også ved mer avansert brystkreft. Dette ble det liv i salen av, selv om noen av tilhørerne så ut til å ryste litt på hode av noen av hans påstander. Imponerende dog at det ved Professor Dixons klinikk i Edinburgh (som er Storbrittanias største i volum brystkreftoperasjoner) i 2011 ble utført 536 BCS tilsvarende 73% av alle pasienter som ble operert for brystkreft, mens han i sitt foredrag påpekte at det nå gjores over 80% BCS.
Robert Smith fra Atlanta gikk nøye gjennom de motstridene publikasjoner om mammografiscreening. Han er en av de fremste forskerne på feltet i USA og belyste den pågående diskusjonen rundt mammografi screeningens fordeler og ulemper. Uenigheten rundt mammografi screeningens nytte, faren for overdiagnostisering og
hvilke tumores som profiterer fra screeningen ble oppsummert. Hans konklusjon var at den store diskrepansen i estimert benefit fra forskjellige publikasjoner er artifisiell og betinget i hvordan data analyseres. Som onkolog kan man vel bare være enig i hans siste setning: “ Until you can tell a patient with measurable, reliable, and persuasive confidence that regular screening offers her no more protection from the risk of a premature death from breast cancer than not screening, regular screening is the best advice.” (viser også til hans artikkel I dette hefte)
Kvelden ble avsluttet litt på overtid av Michael Gnant fra Wien som ga en oversikt over molekylærbiologiske metoder som brukes til å estimere risiko for fjernmetastaser hos pasienter med tidlig brystkreft. Slike metoder er svært ønskelig for å unngå overbehandling av brystkreft pasienter i adjuvant setting som har lav risiko for tilbakefall. Han påpekte at metoder som OncoTypeDx og PAM 50 ROR score er pålitelige og tilstrekkelig validert. Bruk av disse metoder tilfører relevant informasjon når de brukes i tillegg til etablerte klinisk-patologiske faktorer. Ved hans klinikk har bruken av slike metoder ført til endring av adjuvant behandling for et betraktelig antall pasienter.
På veien ut fra møtelokale var det mange fornøyde fjes – så nå er det bare å glede seg til Tema Mamma 2015 og vente i spenning om programmet og tilhørerantallet fra årets møte kan toppes.
Resymes
Separating the marriage between cancer and bone
Professor Robert Coleman
Robert Coleman
Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield Cancer Research Centre, Sheffield, England
Bone metastases result from complex inter-relationships between cancer cells and normal haematopoietic stem cells and bone cells in the bone marrow microenvironment. Disseminated tumour cells home to an then adhere to the haematopoietic stem cell niches in the perivascular space of small bone marrow arterioles at the bone surface where they can remain quiescent and in a dormant state for years. Then, for reasons we do not understand, activation occurs leading to the development of micro-metastatic foci. Bone-targeted treatments such as bisphosphonates have profound effects on the cellular interactions within the bone marrow microenvironment and there is a wealth of pre-clinical data supporting their potential for adjuvant use in the clinic.
Over the past twenty years, many randomised trials of adjuvant bisphosphonates in women with early breast cancer have been conducted with some demonstrating improvements in both disease free and overall survival. However, the trial results have been inconsistent, with benefits appearing to be confined to patients with low levels of reproductive hormones, either premenopausal women receiving ovarian suppression therapy or those who have passed naturally through menopause at the time of diagnosis.
To explore the results of these trials further, an individual patient meta-analysis was conducted by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Data on 17,709 women were analysed that included 3,408 breast cancer recurrences and 2,097 breast cancer deaths respectively. Overall, bisphosphonates had little effect on breast cancer recurrence, distant recurrence or breast cancer mortality. However in 10540 postmenopausal women, adjuvant bisphosphonates significantly reduced breast cancer recurrence (RR=0.86; 2p=.002), distant recurrence (RR=0.83; 2p=<.001), bone recurrence (RR=0.66; 2p=<.001) and breast cancer mortality (0.83; 2p=.004). The magnitude of benefit is of clinical importance and is at least as large as that seen with most of the other routine adjuvant interventions in postmenopausal early breast cancer.
These findings appear to confirm the ability of adjuvant bisphosphonates to beneficially influence tumour dormancy and separate the long term relationships between malignant and host cells that exist in a bone marrow microenvironment that lacks the influences of reproductive hormones on bone cell functions.
Oncoplastic Surgery – Are we doing too little or too much?
Professor J Michael Dixon
J Michael Dixon
Edinburgh Breast Unit, Western General Hospital, Edinburgh, Scotland
Oncoplastic surgery is the combination of surgery to remove a cancer combined with plastic surgery techniques to improve the cosmetic outcome after oncologic surgery. Most people classify oncoplastic surgery as part of breast conserving surgery rather that the reconstructive procedures available after mastectomy. Simple oncoplastic breast conserving surgery involves reshaping the breast to close the defect after wide local excision. More complex oncoplastic surgical procedures consist of more complex reshaping using therapeutic mammaplasty techniques and volume replacement with local flaps. A new addition is combining wide excision with lipofilling. All Breast Units should be able to offer a full range of the more complex oncoplastic breast conserving surgery techniques and this is what will now be considered.
What percentage of women who undergo breast conserving surgery should have complex oncoplastic surgery procedures? Studies from France show that the percentage varies considerably between hospitals. It ranges from 5 – 35%. About 68% of the Units perform these more complex oncoplastic surgery procedures in between 5% and 10% of patients. 8% of Units do less than 5% of these oncoplastic surgery procedures for breast conservation and 4% do between 25% – 50%. A study from Nottingham of the oncological and cosmetic outcomes showed that patients having therapeutic mammaplasty compared with wide excision were twice as likely to have negative margins. Cosmetic outcomes were better for patients having therapeutic mammoplasty than simple breast conserving surgery but there was more pain during recovery and more calcifications on mammograms after the more extensive surgery. Some of the oncoplastic procedures that people have tried in the past should no longer be used such as bat wings and crescents. There are a range of options for patients with larger tumours. The first is neoadjuvant therapy which allows many patients to avoid mastectomy. More patients can have simple wide excisions after neo adjuvant therapy and less require more complex oncoplastic procedures. A particular issue is the increasing number of women having mastectomies for DCIS. It is possible to perform breast conserving surgery for women with even large areas of DCIS with excellent cosmetic outcomes.
In summary about 5% – 10% of patients having breast conserving surgery should have complex oncoplastic procedures such as therapeutic mammaplasty or local flaps. As the range of oncoplastic procedures changes to include lipofilling however increasing women can get good cosmetic outcomes even in large tumours and up to 25% of women are suitable for complex oncoplastic surgery or lipofilling.
Using molecular tools to determine risk of metastasis
Professor Michael Gnant
Michael Gnant
Medical University of Vienna, Vienna, Austria
Our understanding of breast cancer has been considerable improved by molecular profiling during the last decade. Being able to differentiate „luminal“ from „HER2“ and „triple negative“ breast cancer has moreover led to completely different treatmnt standards fro these subtypes which were defined by hierarchical clustering analyses performed on microarray-based gene expression profiles of breast cancers. Since the initial landmark publications by Jack Perou and his colleagues, similar concepts have been used to identify molecular tools to predict the risk of metastasis in eraly breast cancer patients. Both for the crucial question of „Who needs adjuvant chemotherapy?“ as well as for „How long do we have to treat?“, we have now building evidence that molecular assays such as OncotypeDX, Mammoprint, EndoPredict, ProSigna, HOXB13/IL17BR ratio and Breast Cancer Index provide significant and relevant prognostic information concerning the likelihood of recurrence. There are publications describing the prognostic accuracy in comparison to classical clinicopathological factors for early high-risk as well as beyond 5 years after surgery. The identified low-risk subgroups not only show a very favorable prognosis, they also seem to have only little benefit from adjuvant cytotoxic chemotherapy or extended aromatase inhibitor therapyrespectively. Many of these reverse transcriptase/polymerase chain reaction-based techniques have been validated in archived tumor material from large phase III trials, and are increasingly available in routine clinical practice.
CV Professor Coleman
Professor Coleman graduated from Kings College Hospital Medical School, University of London in 1978. Following clinical training in oncology in London and Edinburgh and completion of a research doctorate (MD) in the field of bone metastases, he became senior lecturer and honorary consultant in the newly formed Academic Unit of Clinical Oncology at Weston Park Hospital in 1991.
Following subsequent promotions to Reader in 1996 and Professor in 1999, he has led a large clinical research team and is the director of the Sheffield Cancer Research Centre. Between 2011 and 2013, he was an associate director of the National Cancer Research Network (NCRN). He was Chairman of the National Cancer Research Institute Breast Cancer Study Group in the UK (2004-09) and Past-President of the Cancer and Bone Society (2005-08). His clinical expertise includes breast cancer, gestational trophoblastic disease and cancer induced bone disease. Since 2014 he has been a part time medical director for Prime Oncology, an independent international provider of medical education in oncology.
CV Professor Dixon
Professor Mike Dixon is one of the Great Britain´s leading breast
surgeons, based at the Western General Hospital in Edinburgh.
He is also leader of the Breakthrough Research Unit at the University
of Edinburgh.
In his research work, Mike seeks to understand and overcome resistance to hormonal therapy, which is given to 75% of breast cancer patients. His work has been judged by independent experts as being of the very highest quality.
Mike has become one of the most powerful advocates of Breakthrough’s work in Scotland, making the case for breast cancer research wherever he goes. He is always the first to take part in fundraising activities, having most recently run the Great North Run in 2011 and the Edinburgh Marathon in 2012.
CV Professor Gnant
Michael Gnant is Full Professor of Surgery at the Medical University of Vienna, Austria, where he also serves as President of the Austrian Breast and Colorectal Cancer Study Group.
His medical career began in 1988 when he graduated in medicine in Vienna. He then specialized in surgery (1994) and surgical oncology. In 1997 and 1998 he worked as a Visiting Scientist at the National Cancer Institute, NIH, Bethesda, USA. In 2004, he became Full Professor at the Medical University of Vienna, where he also heads the Breast Health Center. In 2005, he was elected President of the Austrian Breast & Colorectal Cancer Study Group (ABCSG). In 2014, he was appointed as Chairman and Director of the Department of Surgery at the Medical University of Vienna.
Professor Gnant has published more than 350 original papers in peer-reviewed journals, including 77 as first author. His cumulative impact factor is 1.822, with >12.000 citations, an average citation index of 32,