Episode 23: ESMO clinical practice guidelines for early-stage breast cancer

In this episode of WND in breast cancer, Dr Kevin Punie from GZA Hospitals and Prof Evandro de Azambuja from Institut Jules Bordet will focus on  the  recently published clinical  practice  guidelines from  ESMO  for patients  with  early breast cancer.

The latest guidelines from ESMO for patients with early-stage breast cancer reflect significant advancements since 2019, encompassing various subtypes of the disease.

Notably, for HR+/HER2- patients at high risk of relapse, stage 3, olaparib has been incorporated as adjuvant therapy for those with germline BRCA1/HER2 mutations. A standard one-year course of olaparib treatment is now recommended, while high-risk patients lacking this mutation may receive a two-year course of abemaciclib. This delineates clear treatment pathways for very high-risk patients.

Furthermore, recent data shed light on OS and DFS benefits associated with ovarian function suppression in premenopausal patients, particularly those at high risk. Although not universally recommended, this approach can significantly benefit eligible patients.

For triple-negative breast cancer, both treatment strategies and patient selection criteria have evolved substantially. Neoadjuvant therapy guidelines have been refined, extending eligibility beyond node-positive or tumours>2 cm to include T1CN0, T1C, T2, and T3 cases for neoadjuvant chemotherapy. Patients with residual disease and germline mutations may receive olaparib, while those without such mutations may consider capecitabine. For patients with residual disease or pCR to pembrolizumab, monotherapy is a viable option. However, combining pembrolizumab with olaparib or capecitabine is not recommended due to insufficient data. Additionally, patients with T1A, T1B, and N0 tumours would undergo upfront surgery, with chemotherapy decisions made post-operatively based on tumour size, with a more aggressive approach for node-positive disease. A very nice algorithm was developed to decide on which treatment strategy should be used.

In HER2+ breast cancer, aside from minor adjustments, current clinical practices remain consolidated.

Comparatively, differences exist between previous ESMO guidelines and those in the US regarding the utilization of gene expression profiles. While the new guidelines provide some guidance on gene expression and patient selection, they are not overly specific. These profiles can aid in therapeutic regimen selection for patients eligible for chemotherapy with fewer than four lymph nodes, starting from a chemotherapy indication and potentially de-escalating treatment, but not vice versa.