Who should receive combination therapy for ER positive breast cancer?

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Published: 12 Oct 2016
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Dr Michael Gnant - Medizinischen Universität Wien, Vienna, Austria

Dr Gnant speaks with ecancertv at ESMO 2016, reviewing the conference controversy session: Should combined endocrine therapy with targeted agents now be the standard of care for ER metastatic breast cancer?

Weighing cost and safety profile, Dr Gnant thinks further specificity in patient subtypes may streamline treatment selection.

He references the FALCON trial, which has demonstrated the superiority of fulvestrant over anastrazole, as illustrative of the problem in finding preferred combinations when one component may no longer be the best available.


ESMO 2016

Who should receive combination therapy for ER positive breast cancer?

Dr Michael Gnant - Medizinischen Universität Wien, Austria

This morning’s controversy plenary debate, it was actually my colleagues doing a very excellent job of arguing against each other. The question was now, with all this exciting data about combination endocrine therapy plus cyclin inhibitors or mTOR inhibitors, do we have to treat all patients with these combination regimens or are there still patients who are very well treated with a rather similar and cost-effective monotherapy? So the audience was split, as were the speakers, to that question. This reflects that we are struggling in identifying. We all feel that there are patients who are very well off treated with NAI or fulvestrant, particularly based on the excellent FALCON data also presented at this meeting. But we are struggling in identifying between Mrs Smith and Mrs Muller who that actually is. Obviously we don’t want to undertreat our patients and we don’t want to withhold the potential benefit of the combination treatments for them but both on the side effect issue and definitely also in terms of cost for society we need to identify who are the patients who really need the combination approaches and who can be treated, at least in first line, with excellent endocrine therapy alone.

Are there any other comparable trials that you know of?

I’m currently not aware of trials with direct comparisons of these issues; it’s another issue we are struggling with that sometimes the comparator is getting outdated when the experimental combination is presented which happens now to aromatase inhibitors because FALCON clearly showed that fulvestrant is superior so that has been settled very late in the development of that product. But it’s now leading to a struggle of indirect comparison of trials which is never the kind of evidence we want to see before translating something innovative into clinical practice.