Getting It Right in Breast Cancer Means Being More Precise

Patrick I. Borgen, MD

After nearly 30 years as a breast cancer surgeon, Patrick I. Borgen, MD, finds that the most enduring theme in the field is constant change.

“Each time we learn a new piece of the puzzle about breast cancer, we understand that it is a large complex family of diseases,” says Borgen, program chair of the 36th Annual Miami Breast Cancer Conference^® (MBCC). “If there is a theme for this year’s conference, it’s a move away from a one-size-fits all approach to breast cancer in favor of a very targeted one. We are treating breast cancer much more specifically then we ever have.”

Borgen, chairman of the Department of Surgery and director of the Brooklyn Breast Cancer Program at Maimonides Medical Center in New York, said this year’s MBCC will maintain its signature emphasis on presenting oncology specialists across the spectrum of breast cancer care with information they can implement in treating patients.

“We are staying with the format of keeping it practical—our motto has always been ‘Hear it on Friday, use it on Monday,’” he said. “Treating the specific disease and the specific patient that’s in front of us is really what MBCC 2019 is all about.”

In that context, the expert faculty members will take an in-depth look at major developments in diagnostics, new and emerging targeted therapies, immunotherapy, imaging, and surgery, Borgen noted in an interview in advance of the event. “These are enormous advances, and we’ll be doing a deep dive on them,” he said. “We’ll be talking, most importantly, about how and when these advances will be integrated into clinical practice.”

“When I think about breast cancer from 30,000 feet, imagine that we’re attacking it in different ways surgically now than we ever did. There are different radiation options than we ever had. Systematically we can attack estrogen, or HER2, or a variety of different targets, but the key is understanding what we’re treating and matching the treatment to the disease,” Borgen added.

In terms of matching patients with therapies more precisely, Borgen said the findings from the TAILORx study reported in 2018 will have a significant impact on clinical practice. The study found that adjuvant endocrine therapy alone is noninferior to adjuvant chemoendocrine therapy in patients with hormone receptor— positive, HER2-negative, node-negative earlystage breast cancer who have an intermediate risk of distant recurrence based on the 21-gene Oncotype DX Breast Recurrence Score test.¹

Borgen said those findings herald a major change in direction. “In the 1990s, almost every woman with invasive breast cancer in America got chemotherapy,” he said. “Imagine that!”

By contrast, the TAILORx results “will prevent unnecessary chemotherapy in tens of thousands of women. An estimate was made that 60% or 70% of women in this subgroup won’t need chemotherapy…[The results] have expanded the population of women who are at low risk and low benefit from chemotherapy.”

“It’s not just that we’re not seeing an escalation,” he added. “In fact, I could argue we could consider this the year of de-escalation of breast cancer treatment…Genomic profiling has changed the landscape.”

At the same time, refinements are being made in HER2-targeted therapies that also will alter the treatment paradigm, Borgen noted. As an example, he pointed to the results of the phase III KATHERINE study in which ado-trastuzumab emtansine (T-DM1; Kadcyla) reduced the risk of invasive disease recurrence or death by 50% compared with trastuzumab (Herceptin) as an adjuvant treatment for patients with HER2-positive early breast cancer who had residual invasive disease following neoadjuvant therapy.²

Innovations for Patients and Practitioners

“That’s a game changer,” he said.In the spirit of innovation that helps drive MBCC, faculty leaders and conference planners are also introducing new features to the agenda.

For the first time, the conference will feature a patient-focused track, with a day of presentations and events designed for those coping with a cancer diagnosis, their family, and caregivers. Borgen, who will be the keynote speaker for the patient track, said including patients in the conference has been a desirable but challenging goal.

“Sometimes, doctor speak is not patient speak,” he said. “How we find a common voice, a common way to share this information, is really exciting, and patients should be in the audience. I’m a firm believer in that.”

For practicing oncology specialists, changes in the program begin Thursday with a minisymposium featuring tumor board sessions with case reports and panel discussions. On Sunday, the agenda includes the Exigent Matters Workshop. This is an interactive session in which faculty members model how they would approach difficult conversations with patients, such as a discussion about a lack of response to therapy, a diagnosis that turned out to be inaccurate, or a problem with clinical trial eligibility.”

“We challenge our faculty to break news that’s not favorable to a hypothetical patient, and then we sort of rate their style on what worked and what didn’t work,” Borgen explained. “We did it last year for the first time, and it was a huge hit with the audience.”

References

1. Sparano JA, Gray RJ, Makower DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018;379(2):111-121. doi: 10.1056/NEJMoa1804710.
2. von Minckwitz G, Huang C-S, Mano MS, et al; KATHERINE Investigators. Trastuzumab emtansine for residual invasive HER2-positive breast cancer. N Engl J Med. 2019;380(7):617-628. doi: 10.1056/NEJMoa1814017.

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