A/Prof Nick Wilcken
A new ESMO Clinical Practice Guideline for the diagnosis, staging and treatment of patients with metastatic breast cancer provides “sensible, practical” advice that is very relevant to clinicians everywhere, including in Australia.
The 60-page guideline, published in Annals of Oncology, provides >80 evidence-based recommendations but also emphasises the importance of shared decision making.
“Treatment decisions need to be made independent of patient age, but comorbidities and patient characteristics, as well as patient preferences, need to be considered as part of a shared decision-making process. In elderly patients, a comprehensive geriatric assessment may add important information,” it said.
The guideline includes a number of proposed algorithms for the diagnostic work-up of metastatic breast cancer and the management of different breast cancer subtypes as well as oligometastatic disease.
Associate Professor Nick Wilcken, from the Westmead Breast Cancer Institute, told the limbic that management of metastatic breast cancer was complicated, and can’t be protocolised too much.
“I might be dealing with a 40 year old woman with terrible disease, or I might be dealing with an 80 year old woman with a few spots in her bones who is probably going to live for another 10 years. It’s so variable.”
He said the ESMO guideline was a sensible real-world document that didn’t proscribe things too much.
“It lays out options but leaves plenty of space for individual decision making,” he said.
Many of the recommendations including those for primary stage IV disease, oligometastatic disease and bone metastases suggest therapeutic decisions should be made within the context of a multidisciplinary team (MDT).
Associate Professor Wilcken said while clinicians are used to discussing early breast cancer cases in the MDT, it was more of a challenge to have formal sit-down meetings for metastatic disease.
He said the smaller numbers of patients and the iterative process of lengthy management contributed to the difficulty.
“But otherwise it is just a reminder that we keep our networks and discuss things with our radiation oncology and our surgeon colleagues.”
He said the guideline also recommended the use of biomarkers that were not routinely measured locally such as BRCA, PD-L1 and PI3 kinase mutations.
“They are very sensible and characteristics of the cancer that might direct new treatments but the new treatments are not available on the PBS yet.”
For example, “If we knew that a woman had a BRCA mutation and she has got metastatic disease, there is very good evidence that these new PARB inhibitors like olaparib is helpful. But it’s not yet on the PBS.”
“It’s sensible to point that out and that is the way of the future but at the moment, for Australian oncologists, we don’t have access to those drugs on the PBS.”
Associate Professor Wilcken also noted the guideline said there is no evidence that the type of imaging used for staging or monitoring of disease has an impact on outcomes.
He concluded: “I would find it very reassuring that the guideline essentially follows and supports Australian standard practice, the only exceptions being that there are some drugs that are not yet available in Australia but no doubt will be in the near future.”
Professor Sherene Loi, from the Peter MacCallum Cancer Centre, is one of the coauthors of the ESMO guideline.