What will be the big developments and issues we can expect to see in breast cancer management in 2018? Medical oncologist Associate Professor Nicholas Wilcken gives his view.
1. The role of immunotherapy in treating breast cancer
While we know immunotherapy is effective in cancer, a major issue in 2018 is whether immunotherapy can be as effective in breast cancer as it is in other cancers such as melanoma. There is evidence to suggest that it may be effective for triple negative breast cancer and for HER2+ cancer. The challenge for 2018 will be to see which [combinations of] therapies and which patients will best response to immunotherapy.
2. Clarify the role of CDK 4/6 inhibitors
Trials have shown the cyclin-dependent kinase (CDK) 4/6 inhibitors to be effective in ER-positive+ disease. Trials are now needed to assess whether there is a role for the CDK inhibitors in HER2+ disease.
3. De-escalation of therapy
It’s an unsexy area, but it’s clear that we are overtreating people with breast cancer in some circumstances. More treatment does not necessarily mean better treatment. We need more trials looking at this, where there is questionable efficacy of treatments in breast cancer. But it’s hard to do. Once you start a treatment it’s a very brave person who says they are going to stop it.
Examples of where we might scale back therapy include
- Omission of surgery in low grade DCIS
- Omission of axillary surgery in some cases
- The potential for shorter duration of adjuvant Herceptin (trastuzumab) threatment
- Omission of breast radiotherapy in some circumstances
Associate Professor Wilcken is Director of Medical Oncology at the Westmead Cancer Care Centre, Senior Staff Specialist at Nepean Hospital, and Associate Professor of Medicine, University of Sydney.