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Appropriate Duration of Endocrine Therapy in Breast Cancer

Panelists:Adam M. Brufsky, MD, University of Pittsburgh; Sara A. Hurvitz, MD, David Geffen School of Medicine; Joyce A. O'Shaugnessy, MD, Baylor Charles A. Sammons Cancer Center; Hope S. Rugo, MD, University of California; Christy A. Russell, MD, University of Southern California
Published: Wednesday, Feb 17, 2016


Transcript:

Adam M. Brufsky, MD:
One last thing before we go because this is the one last early breast cancer question that we actually have here. We get back to this, the 5-vs-10 year question? Do any of you use the molecular profiling now, the tests like Prosigna or the Breast Cancer Index, to determine whether people should be 5 or 10 years of total endocrine therapy?

Hope S. Rugo, MD: I think it’s a really good idea, and I have never used it.

Adam M. Brufsky, MD: You think it’s good and you have never used it, all right.

Hope S. Rugo, MD: I can’t see sending in a test at five years. I’m afraid no one will approve it anyway.

Adam M. Brufsky, MD: Actually, they will. Believe it or not, they have.

Hope S. Rugo, MD: Maybe not in California.

Adam M. Brufsky, MD: Sara, what do you think? Have you used it?

Sara A. Hurvitz, MD: I’m not using it now. So much of this is a long conversation. Some patients have been waiting for that five-year mark to come up for five years, because of the symptoms and side effects they’re having from therapy. Other women really want to continue their therapy. They’ve tolerated it, they had a high risk, and they feel like it’s their crutch saving them from metastatic recurrence. So usually the patients already know what they want to do. The conversation has been predetermined.

So I haven’t found a setting where I really need to have that conversation with patients, and a lot of my patients have become menopausal in those five years. We know they’re higher-risk, and now we can switch them to an aromatase inhibitor. So that’s helpful. It just hasn’t come up so much in the clinic for me.

Adam M. Brufsky, MD: So it sounds like very few people use it.

Joyce A. O’Shaughnessy, MD: No, I just think we need more data. There’s going to be a treasure trove of data coming out in the next few years. As I said, I do kind of pay attention to that recurrent score. And my kind of rule-of-thumb, as I said, the really strong ER and low-proliferative are those that probably had the lower metastatic potential, and perhaps are so endocrine therapy–sensitive, even if they did have metastatic potential, that their benefit from more endocrine therapy may be very, very marginal. Not necessarily zero, but very marginal—where I worry. And then conversely, those with a low ER and the high-proliferative, their natural history plays out pretty quickly and their endocrine therapy sensitivity ain’t that great.

Adam M. Brufsky, MD: Right. Things like Oncotype and whatever, or clinical correlation, those are the first five-year people.

Joyce A. O’Shaughnessy, MD: Correct.

Adam M. Brufsky, MD: But I’m thinking more now it’s five years out. A woman has come in, she’s miserable, she has hot flashes.

Hope S. Rugo, MD: Well, you’re always balancing risk and benefit, you know that.

Adam M. Brufsky, MD: Right. And she’s looking for a way out. Maybe she’s node-positive. She’s looking for a way out. These tests are not valid for node-positive.

Joyce A. O’Shaughnessy, MD: I make strong recommendations. You know obviously, the ladies, like you said, they have their own very, very strong opinions, too. But I make strong recommendations whether to stay on or not because what worries me is the woman who has some tumor burden, and strong ER, and some proliferation. That’s where I think that a lot of these tests that are out there, the EndoPredict, the BCI, really what they’re getting at is ER signaling and proliferation.

At the end of the day, we’re going to have an algorithm. We can plug it into the computer, and we’re going to have clinical and well done, centrally done, standardization of Ki-67, for example. We’re going to be able to push a button and we’re going to be able to tell these ladies, but I think some of the biology is beginning to come clear on it.

Sara A. Hurvitz, MD: What I struggle with most right now is my postmenopausal high-risk women who are ending five years.

Adam M. Brufsky, MD: Yeah, there are no data.

Hope S. Rugo, MD: Right. What do we do with the aromatase inhibitor?

Sara A. Hurvitz, MD: Yes.

Hope S. Rugo, MD: And I think we just don’t know. The Breast Cancer Index, though, looks at something a little bit different. You know, it’s kind of an interesting question because there are probably those who have low-proliferative, strongly ER-PR–positive disease who still have a significant risk of relapse at year 12, and we may impact outcome in some of those women. I just don’t know, you know, balancing it. We need more data, I totally agree.

Adam M. Brufsky, MD: I think that’ll come. I think a lot of people are going to be using the blocks from B42, which is the study looking at the 5-vs-10 year benefit from therapy. All of these tests, like EndoPredict.

Joyce A. O’Shaughnessy, MD: Which I hear is going to come out in ’16.

Adam M. Brufsky, MD: Oh, hopefully.

Joyce A. O’Shaughnessy, MD: I heard that from Terry Mamounas. Yeah, Terry said ’16, so I tell the patients that.

Adam M. Brufsky, MD: Well, hopefully there will be a lot of correlative studies that will help us figure out this question.
                                                                                                                                                                                                                                                                                                                
Transcript Edited for Clarity
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Transcript:

Adam M. Brufsky, MD:
One last thing before we go because this is the one last early breast cancer question that we actually have here. We get back to this, the 5-vs-10 year question? Do any of you use the molecular profiling now, the tests like Prosigna or the Breast Cancer Index, to determine whether people should be 5 or 10 years of total endocrine therapy?

Hope S. Rugo, MD: I think it’s a really good idea, and I have never used it.

Adam M. Brufsky, MD: You think it’s good and you have never used it, all right.

Hope S. Rugo, MD: I can’t see sending in a test at five years. I’m afraid no one will approve it anyway.

Adam M. Brufsky, MD: Actually, they will. Believe it or not, they have.

Hope S. Rugo, MD: Maybe not in California.

Adam M. Brufsky, MD: Sara, what do you think? Have you used it?

Sara A. Hurvitz, MD: I’m not using it now. So much of this is a long conversation. Some patients have been waiting for that five-year mark to come up for five years, because of the symptoms and side effects they’re having from therapy. Other women really want to continue their therapy. They’ve tolerated it, they had a high risk, and they feel like it’s their crutch saving them from metastatic recurrence. So usually the patients already know what they want to do. The conversation has been predetermined.

So I haven’t found a setting where I really need to have that conversation with patients, and a lot of my patients have become menopausal in those five years. We know they’re higher-risk, and now we can switch them to an aromatase inhibitor. So that’s helpful. It just hasn’t come up so much in the clinic for me.

Adam M. Brufsky, MD: So it sounds like very few people use it.

Joyce A. O’Shaughnessy, MD: No, I just think we need more data. There’s going to be a treasure trove of data coming out in the next few years. As I said, I do kind of pay attention to that recurrent score. And my kind of rule-of-thumb, as I said, the really strong ER and low-proliferative are those that probably had the lower metastatic potential, and perhaps are so endocrine therapy–sensitive, even if they did have metastatic potential, that their benefit from more endocrine therapy may be very, very marginal. Not necessarily zero, but very marginal—where I worry. And then conversely, those with a low ER and the high-proliferative, their natural history plays out pretty quickly and their endocrine therapy sensitivity ain’t that great.

Adam M. Brufsky, MD: Right. Things like Oncotype and whatever, or clinical correlation, those are the first five-year people.

Joyce A. O’Shaughnessy, MD: Correct.

Adam M. Brufsky, MD: But I’m thinking more now it’s five years out. A woman has come in, she’s miserable, she has hot flashes.

Hope S. Rugo, MD: Well, you’re always balancing risk and benefit, you know that.

Adam M. Brufsky, MD: Right. And she’s looking for a way out. Maybe she’s node-positive. She’s looking for a way out. These tests are not valid for node-positive.

Joyce A. O’Shaughnessy, MD: I make strong recommendations. You know obviously, the ladies, like you said, they have their own very, very strong opinions, too. But I make strong recommendations whether to stay on or not because what worries me is the woman who has some tumor burden, and strong ER, and some proliferation. That’s where I think that a lot of these tests that are out there, the EndoPredict, the BCI, really what they’re getting at is ER signaling and proliferation.

At the end of the day, we’re going to have an algorithm. We can plug it into the computer, and we’re going to have clinical and well done, centrally done, standardization of Ki-67, for example. We’re going to be able to push a button and we’re going to be able to tell these ladies, but I think some of the biology is beginning to come clear on it.

Sara A. Hurvitz, MD: What I struggle with most right now is my postmenopausal high-risk women who are ending five years.

Adam M. Brufsky, MD: Yeah, there are no data.

Hope S. Rugo, MD: Right. What do we do with the aromatase inhibitor?

Sara A. Hurvitz, MD: Yes.

Hope S. Rugo, MD: And I think we just don’t know. The Breast Cancer Index, though, looks at something a little bit different. You know, it’s kind of an interesting question because there are probably those who have low-proliferative, strongly ER-PR–positive disease who still have a significant risk of relapse at year 12, and we may impact outcome in some of those women. I just don’t know, you know, balancing it. We need more data, I totally agree.

Adam M. Brufsky, MD: I think that’ll come. I think a lot of people are going to be using the blocks from B42, which is the study looking at the 5-vs-10 year benefit from therapy. All of these tests, like EndoPredict.

Joyce A. O’Shaughnessy, MD: Which I hear is going to come out in ’16.

Adam M. Brufsky, MD: Oh, hopefully.

Joyce A. O’Shaughnessy, MD: I heard that from Terry Mamounas. Yeah, Terry said ’16, so I tell the patients that.

Adam M. Brufsky, MD: Well, hopefully there will be a lot of correlative studies that will help us figure out this question.
                                                                                                                                                                                                                                                                                                                
Transcript Edited for Clarity
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