Kathy D. Miller, MD


December 05, 2017

Hi. It's Dr Kathy Miller from Indiana University. Thanksgiving has passed, and for those of us in the breast cancer world, that means we are starting to shift our eyes toward roasted chilis and the 2017 San Antonio Breast Cancer Symposium (SABCS). I will be headed there next week, and I wanted to give you a bit of a head's-up on some of the important studies that I am looking forward to seeing at the meeting.

Adjuvant Trastuzumab for Low-Level HER2-Expression Breast Cancer

First, there is a study that I think many of us have forgotten about. A study coordinated by our colleagues in the NRG Research Group[1] looked at whether trastuzumab as a component of adjuvant therapy might reduce the risk for recurrence in patients with low-level HER2 expression—1+ by immunohistochemistry or 2+ but FISH negative—who we would not currently treat with trastuzumab.

I thought from the beginning that this was a fool's errand and that this was going to be a negative study, but I have to give my NRG colleagues credit for testing this hypothesis. If they are right and there is a benefit, this will have an immediate and huge impact on all of our practices. We definitely want to look for those results.

Bisphosphonates and Denosumab

We will see some other data looking at adjuvant bisphosphonates[2] and denosumab.[3] We have seen several studies looking at these areas over the years. While the results have been a bit inconsistent, there is a general message that they are helpful and reduce the risk for recurrence in patients with ER+ disease receiving endocrine therapy. But they really have not been incorporated in practice yet. We will look at these data again and see whether we have reached that tipping point, where we are all now willing to embrace this as a component of adjuvant therapy, even in patients with normal bone density.


I also want to draw your attention to another important aspect of endocrine therapy, and this is a study by Dawn Hershman and her colleagues. Dawn has long recognized the importance of helping our patients be adherent to long-term endocrine therapy. There are a lot of barriers to taking a medicine for a prolonged period of time. Hormone therapy is not a freebie and it has some real toxicities that lead to at least a third or more of our patients stopping their therapy long before they have received the maximum benefit.[4]

The most recent study from Dawn and her colleagues[5] looked at acupuncture—a treatment that does not involve drugs and might be very acceptable to many patients but is not always widely available in experienced hands. It will be fascinating to see whether this is helpful. Then we can think about how we might take advantage of this and the challenges of incorporating acupuncture into our practices on a routine basis.

Predicting Late Recurrence

Finally, I want to give credit to some work from one of my trials, the ECOG5103 trial. That trial, you will recall, looked at bevacizumab in the adjuvant setting.[6] It was absolutely a negative trial, but we have been able to continue to learn from that experience with patients who enrolled in a substudy that collected blood samples annually from years 5 to 10, looking for predictors of late recurrence.[7] Our hope is that this could help us identify patients who might be interested in clinical study of novel agents long after initial diagnosis because they remain at high risk for recurrence. Conversely, this could help us identify patients at very low risk who maybe do not need to accept long-term endocrine therapy at all.

These are early days. The results being presented by my colleague, Joe Sparano, should not impact your practice. Let me say that again: These are not results for you to go home and put into practice, but they do give us a glimpse of the future and how we will be able to individualize ongoing endocrine therapy for our patients. And that is something really exciting.

If you are in San Antonio, I hope to see you there. Let us know what you think are the most important findings from this year's meeting. I will be there talking to some of my colleagues and bringing you some more in-depth results as we all learn about them together.


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