Treating HR+/HER2− breast cancer in premenopausal Asian women: Asian Breast Cancer Cooperative Group 2019 Consensus and position on ovarian suppression
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Breast cancer in young Asian women has distinctive clinicopathological characteristics; hence, we question the universal generalizability of treatment recommendations based on data from predominantly non-Asian postmenopausal women.
The Asian Breast Cancer Cooperative Group (ABCCG) reviewed current ESO-ESMO and St. Gallen recommendations for treating hormone receptor positive/human epidermal growth factor receptor 2 negative (HR+/HER2−) breast cancer in premenopausal women. Points disputed by ≥ 3/12 members were discussed, and statements on contentious issues formulated for anonymous voting; consensus required a ≥ 75% majority.
The ABCCG contends that: (1) Trials in premenopausal women are not only necessary, but also worthwhile if performed separately from others that also enroll postmenopausal participants. (2) Not all premenopausal women with HR+ early breast cancer need adjuvant ovarian function suppression (OFS). (3) Certain clinical factors might influence decision-making about prescribing OFS. (4) For early HR+/HER2− breast cancer in premenopausal patients with OFS, tamoxifen is preferred for intermediate-risk cases; for high risk, near-consensus supported aromatase inhibitor, despite no clear overall survival benefit versus tamoxifen. (5) Oncotype DX Breast Recurrence Score® has different treatment implications in patients aged ≤ 50 versus > 50 years. (6) High-risk patients (if premenopausal after chemotherapy) should receive adjuvant chemotherapy and OFS plus aromatase inhibitor. (7) For patients with advanced disease receiving OFS on a backbone of tamoxifen, gonadotrophin-releasing hormone agonists may be given 12-weekly. (8) For premenopausal women who decline OFS or oophorectomy, tamoxifen alone is still an option but is considered less effective; other monotherapies are also less effective than OFS plus such treatments.
Premenopausal Asian women with breast cancer have unique disease characteristics and may benefit from treatment that differs somewhat from international guidelines. Given the great diversity of patients and clinical settings worldwide, the ABCCG advocates evidence-based yet flexible and individualized use of all potential options to improve breast cancer outcomes.
KeywordsAsia Premenopausal breast cancer Treatment Ovarian suppression Combined endocrine therapy CDK4/6 inhibitor
Asian Breast Cancer Cooperative Group
European School of Oncology and European Society for Medical Oncology
- ABC 4
ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer, fourth edition
Hormone receptor positive
Human epidermal growth factor receptor 2 negative
Ovarian function suppression
Ovarian function ablation
Gonadotrophin releasing hormone agonist
Novartis supported administrative organization of the ABCCG consensus survey and meeting, and third-party assistance with manuscript development. However, Novartis took no direct role in developing this Consensus Statement; the ABCCG members independently agreed each consensus point, wrote the manuscript, and decided to publish the final version. Dr. David Neil (PhD), of Full Universe Integrated Marketing, Taiwan, provided professional editorial and medical writing services, and his colleague Ms. Anabelle Huang assisted with manuscript preparation project management; these contributions were supported by funding from Novartis.
Compliance with ethical standards
Conflict of interest
The authors have all participated as faculty members of Novartis Breast Cancer Advisory Boards, and received personal fees, reimbursement of travel expenses, and/or hospitality for their service in this capacity. However, the ABCCG is a professional association that was constituted and operates independently of Novartis and which sets its own research agenda. The article discusses specific Novartis products within the context of the current breast cancer therapeutic landscape, which the authors strove to review impartially. All views expressed are the authors’ own, and do not necessarily represent those of Novartis. The authors declare competing interests. WY reports consultancy/advisory roles and receipt of personal fees for Novartis, Pfizer, AstraZeneca, Eli Lilly, Roche, and Amgen. TU reports receiving personal fees and non-financial support from Novartis KK, and personal fees from Chugai, Eisai, AstraZeneca KK, and Taiho. CHL reports a consultancy/advisory role for Novartis. QL reports a consultancy/advisory role and personal fees for Novartis, and receipt of personal fees from Pfizer, Roche, AstraZeneca, and Eisai. KHL reports consultancy/advisory roles with Novartis, AstraZeneca, Roche, Ono, Eisai, Bayer, and Samsung Bioepis. RL reports a consultancy/advisory role with Novartis. YN reports research funding and a consultancy/advisory role for Roche Diagnostics, and consultancy/advisory roles for Novartis, Pfizer, Taiho, Nippon Kayaku, Eli Lilly, AstraZeneca, Merck Serono, Bayer, Meiji Seika, Chugai, and Eisai. YHP reports research funding and consultancy/advisory roles for Novartis, Pfizer, Eisai, and research funds from AstraZeneca, and Roche. SAI reports research funding from AstraZeneca, research funds and a consultancy/advisory role for Pfizer, and consultancy/advisory roles with Novartis, Hanmi, Roche, Pfizer, Amgen, and Eisai. HL reports research funding and a consultancy/advisory role for Roche Diagnostics, and consultancy/advisory roles with Novartis, Pfizer, Eli Lilly, and AstraZeneca. YSY reports personal fees and a consultancy/advisory role for Novartis, receiving personal fees and non-financial support from Pfizer, AstraZeneca, Lilly, and non-financial support from Eisai, and Roche. YSL reports receiving research funds and personal fees from Novartis, Pfizer, Roche, and Merck Sharp & Dohme, and personal fees from Boehringer Ingelheim.
This work did not entail studies of human participants by any of the authors.
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