June 2008: Updates from the 2008 ASCO Annual Meeting

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Explain BRCA status difference among sisters?

Question from Winfrey: At age 44 I was diagnosed and treated for invasive breast cancer and my younger sister subsequently was diagnosed at that same age. We both have been tested for the BRCA1 and BRCA2 gene. However, my results were positive for the BRCA2 variant and hers were negative for both. Are there any current studies that would explain this?

Answer —Generosa Grana, M.D., F.A.C.P.: What's not clear from the question is whether you carry a variant in BRCA2 that is sometimes described as a variant of indeterminate significance. Those variants are not well-understood and their contributions to breast cancer are not well-defined. And it is not unusual with family members for one to carry it and one not to carry it. I call these results truly uninformative, and would tell you that other family members need to be considered high-risk and monitored aggressively. You and your sister should stay tuned as more research is ongoing, hoping to unravel other genes that are related to breast cancer, and also to unravel the role that these variants play in breast cancer.

Link between LCIS and ILC? Okay to decline tamoxifen?

Question from Jane6: What is the current thinking on LCIS as a precursor to invasive lobular carcinoma? What is the best treatment for LCIS other than vigilance? Is it appropriate for premenopausal women with a weak family history to decline tamoxifen?

Answer —Carol Kaplan, M.D.: LCIS is still considered a risk factor for development of breast cancer. There is some preliminary research that questions the link between LCIS and invasive lobular carcinoma. However, we have been unable to definitively demonstrate that LCIS has a natural history that leads to invasive cancer directly. Taking tamoxifen is a personal decision, and as long as you feel you have been informed of its particular benefits in breast cancer risk reduction, you can choose close surveillance, including annual MRI and mammography in place of tamoxifen.

Updates on HERA study?

Question from KathyM: Are there any updates about the 2-year arm of the HERA study? I was in the 2-year study and am very interested, especially around relapse. Thank you.

Answer —Generosa Grana, M.D., F.A.C.P.: There is no data yet available on the HERA group that received 2 years of Herceptin (chemical name: trastuzumab). For the present, the standard remains 1 year of therapy. And we look forward to that data becoming available.

Zometa standard for lowering recurrence risk?

Question from KWood: Do you think it likely that at some point infusions of Zometa will be considered standard practice for reducing the risk of recurrence with ER-positive early-stage breast cancer? Does it make sense for patients to request it "off-label" now?

Answer —Generosa Grana, M.D., F.A.C.P.: Zometa (chemical name: zoledronic acid) is a very interesting drug, currently FDA approved for treatment of metastatic breast and prostate cancer to bone as well as for refractory osteoporosis. Recent data presented both at the San Antonio Breast Cancer Symposium and ASCO suggest that it may indeed play a role in prevention of early breast cancer recurrence. It is too early to adopt this as a standard therapy for early breast cancer. There are several studies, two of them completed and one of them ongoing, that will shed more light on this issue. But at this point, I don't believe it is standard of care, nor should physicians be prescribing this outside of its indications until that data becomes available.

News on ILC and its treatment?

Question from MWahl: Please update us on any new research regarding invasive lobular cancer and its treatment.

Answer —Generosa Grana, M.D., F.A.C.P.: There is as-yet no clear distinction about treatment between invasive lobular and invasive ductal carcinoma. There is some early data suggesting that invasive lobular may be less responsive to pre-operative chemotherapy, but in general, most of us don't make concrete decisions about treatment on the basis of only lobular versus ductal histology.

Updates on anthracyclines and Topoll-2 gene?

Question from RuthB: Last year research suggested that anthracyclines may not benefit most women, but only those with the Topoll-2 gene. Any updates on this? Has a commercial test for this gene been released yet, and if one already had chemo with an anthracycline, would it be of any value to have the test?

Answers —Generosa Grana, M.D., F.A.C.P.: No new data has been presented since Dr. Slamon presented data on Topoll-2 and its relationship to anthracycline activity. There is a commercially available test to make decisions about the use of anthracyclines in breast cancer, but I'm not aware of anyone who is using it. And this test would be of absolutely no value to someone who has already had anthracycline and remains cancer-free. This is an area of much debate in breast cancer right now. There is a great interest in trying to narrow down who should get anthracycline and where the risk of cardiac toxicity may be acceptable versus those patients that could be treated with other regimens, such as taxanes. This remains an open question.

Carol Kaplan, M.D.: It's important to recognize that Topoll-2 activity comes in conjunction with HER-2 activity. It does not seem that those patients who get Herceptin get additional benefit from anthracycline regimens when compared to regimens that do not contain anthracycline. Although this data is preliminary, it seems that the benefits of trastuzumab are present with or without anthracycline.

Results of TAILORx trial?

Question from Anne: Are there any preliminary results available on the TAILORx trial yet? When do you expect that data to be known?

Answer —Generosa Grana, M.D., F.A.C.P.: The TAILORx trial is currently enrolling patients and is a relatively young trial in terms of overall accrual. While not having at hand the number of patients that are currently on the study, I would anticipate another 1 to 2 years of enrollment. So it is unlikely that we will have results from that trial for several years to come.

Evista over Arimidex after lumpectomy and radiation?

Question from Mare74: I am at high risk for cardiac disease. I am taking Arimidex after lumpectomy and radiation and am interested in your opinion on the new results on trials of Evista.

Answer —Generosa Grana, M.D., F.A.C.P.: While Evista (chemical name: raloxifene) is an interesting drug, its role is established only in the prevention setting, e.g., high-risk women using the drug to reduce their risk of breast cancer. There is very little data of Evista in metastatic breast cancer and none in either invasive disease or ductal carcinoma in situ. So for invasive breast cancer, the options remain tamoxifen or an aromatase inhibitor, such as Arimidex (chemical name: anastrozole), Femara (chemical name: letrozole), or Aromasin (chemical name: exemestane). There is no role in these patients for Evista.

New treatments for vision/speech problems with metastasis?

Question from Steve: My wife has metastatic breast cancer. It is believed that she is experiencing increased cranial and spinal fluid pressures that are causing her double vision and slurred speech. She's taking Dexamethasone to reduce the swelling, but with very little effect. Are there new treatments for these symptoms? Thank you for assisting all of us.

Answer —Generosa Grana, M.D., F.A.C.P.: It appears that what you may be describing is a syndrome known as carcinomatous meningitis. Unfortunately, this is a setting in which treatments are difficult. Steroids can be helpful in some, and radiation encompassing the brain and spine can be helpful in some. But the use of these things needs to be discussed in detail with the treating oncologist. There are medications that can be instilled directly into the spinal fluid, called intrathecal chemotherapy, but its activity is limited. Again, working carefully with the oncologist is the most important thing in this setting.

Minimize joint/leg pain from aromatase inhibitors?

Question from Nancy: Dr. Grana, I recently heard you speak at St. Barnabas and was intrigued by your recommendations for treatment of the side effects of the aromatase inhibitors (I'm on Femara). Is there anything else that can be done to minimize or get rid of the severe joint pain and leg pain that I am having as a result of Femara? I had been on Arimidex, but switched over because of the same problem. Thanks.

Answers —Generosa Grana, M.D., F.A.C.P.: The arthritic symptoms associated with the aromatase inhibitors can be very problematic and occur with all three of the aromatase inhibitors. Some have suggested that there may be a relationship with preceding arthritis, or that there may be a relationship with low Vitamin D levels. But by and large, it is difficult to predict who will get these arthritic symptoms which, once they occur, are difficult to treat. I personally often switch from the non-steroidal aromatase inhibitors such as Arimidex and Femara to the steroidal compound Aromasin. Sometimes that can be helpful, but other clinicians don't necessarily find that to be the case. We all rely on things such as non-steroidal agents such as ibuprofen and agents such as glucosamine and chondroitin sulfate, but the reality is none of these things are perfect. And some women will ultimately, due to the severity of their symptoms, revert to tamoxifen, which appears to have less of these arthritic symptoms.

Carol Kaplan, M.D.: I also have success with changing which aromatase inhibitor a patient takes, although this success is not universal. It seems that increased activity or exercise levels affords some benefits to these patients and can help to diminish the symptoms. Finally, there is some reported data indicating that acupuncture may be helpful in patients with these symptoms.

News on Ixempra and Xeloda for metastasis?

Question from JenniferJ: My friend is on Ixempra and Xeloda after liver mets (she is triple-negative and it metastasized quickly, but only to one spot). Have further studies been published on this combo since the last year's conference? What other chemo options should her docs consider if this is not effective?

Answers —Generosa Grana, M.D., F.A.C.P.: That is the best data that is currently available, with Ixempra (chemical name: ixabepilone) and Xeloda (chemical name: capecitabine). There are several studies ongoing with various drugs in combination with Ixempra and all we know is that it is a drug that appears to have good activity in breast cancer. One thing to consider, if the disease is only in the liver and is of limited extent, there are potentially some strategies to treat the liver locally. You can do chemoembolization or other similar strategies to target the liver specifically. But that is usually limited to a small number of lesions, 3 or 4 lesions, which is usually not the case for most patients that have liver involvement. What other strategies are there that may be specific to triple-negative disease? Platinum compounds (carboplatins) may be a particularly interesting drug, but I would also look for some investigational studies that are being done across the country targeting triple-negative disease. Being part of a clinical trial is a great way to get access to new drugs.

Carol Kaplan, M.D.: Next month's conference will be focusing on triple-negative breast cancer. The date is July 16 with Dr. George Sledge and Dr. Beth Baughman DuPree.

Results of Avastin/Taxotere trial?

Question from Linda: Can you talk about the results from the Avastin/Taxotere trial? What does it mean for metastatic patients?

Answer —Carol Kaplan, M.D.: The data presented at ASCO this year on docetaxel (brand name: Taxotere) and bevacizumab (brand name: Avastin) reveal that the addition of bevacizumab to docetaxel therapy yields greater efficacy. However, when compared to the paclitaxel (brand name: Taxol) and bevacizumab trial results, it seems that the docetaxel regimen comes with greater toxicity. For this reason, I personally at this time would choose to use paclitaxel with bevacizumab.

Bisphosphonates all the same? Zometa for post-menopause?

Question from ChessM: Are all bisphosphonates the same? Are there any clinical trials that are currently under way that are testing Zometa with post-menopausal breast cancer survivors?

Answer —Generosa Grana, M.D., F.A.C.P.: All bisphosphonates are not the same. They vary in their strength and their toxicity, and what role they each play in early-stage breast cancer is not yet well defined. The oral bisphosphonates -- clodronate (which is FDA approved in Europe for osteoporosis), Actonel (chemical name: risedronate), Fosamax (chemical name: alendronate sodium), and Boniva (chemical name: ibandronate), which are all approved by the FDA in the U.S., are all oral bisphosphonates of varying activity. They are less intensive than Zometa. There are several trials going, both in the United States and Europe, looking at all of these bisphosphonates in post-menopausal women with breast cancer. Again, we eagerly await the results of those trials to see if these agents have varying levels of anti-cancer activity as well as varying levels of toxicity.

Studies on tamoxifen dosage and side effects?

Question from SunnyA: I am taking tamoxifen after a partial mastectomy and radiation (no lymph node involvement, no chemo) but the side effects are horrible -- unbearable hot and cold flashes and severe joint pain. Have there been studies done to see if lowering the dosage helps with the side effects without significantly reducing its effectiveness?

Answer —Generosa Grana, M.D., F.A.C.P.: There have not been any trials looking at modification of the dose of tamoxifen to see how much that will improve side effects and how it will affect effectiveness. You may be happy to know that there is some data that the women who metabolize tamoxifen most actively and get the most anti-cancer benefit from tamoxifen are those same women who have more of the hot flashes, night sweats, and other symptoms. So again this may be reassuring to know that you are getting good activity, but are having to pay the price as far as toxicity.

PARP inhibitors to treat BRCA defects?

Question from PondsG: PARP inhibitors are being tested for efficacy against BRCA1 and 2 defects in breast and ovarian cancers. Is there any indication as to whether such treatments are likely to benefit both types? Is there any hope for a recurrence-preventive trial for those affected?

Answer —Carol Kaplan, M.D.: PARP inhibitors are drugs intended to target specifically the BRCA mutation carrier population. We happen to have an open clinical trial at the University of Pennsylvania that is currently enrolling breast cancer patients with metastatic disease. There has already been reported promising data for PARP inhibitor therapy for the treatment of ovarian cancer, fortunately. And preliminary clinical data in the breast cancer population suggests that this therapy could be worthwhile.

Most important update for metastatic patients?

Question from SmithS: What was the most important update for metastatic patients (particularly HER2 patients)?

Answer —Generosa Grana, M.D., F.A.C.P.: I would say that the most exciting thing was the realization that there is improved understanding of the pathways involved in breast cancer, including the HER2 pathway, and that various strategies are being used to approach those pathways jointly. It will no longer be an issue with having only trastuzumab. There was interesting data combining trastuzumab and lapatinib (brand name: Tykerb) , as well as incorporation of other agents that may play a role in this pathway. So the future for HER2 positive disease looks very promising.

Aromatase inhibitor use beyond five years?

Question from Zelensk: Is there any support for extending the use of aromatase inhibitors beyond the 5-year time period? Are there any circumstances where it might be warranted?

Answer —Generosa Grana, M.D., F.A.C.P.: There are currently ongoing trials looking at extending aromatase inhibitors beyond 5 years. One such trial being conducted by the NSABP is giving women finishing 5 years of an aromatase inhibitor 5 more years of either letrozole or a placebo. Thus far, we have no data to do anything more than 5 years of therapy. Personally, I would consider longer therapy in a truly high-risk woman (multiple lymph nodes involved, inflammatory disease, or locally advanced disease). Many of those women will not be eligible for the national trial and we definitely discuss this and come to a decision together. The woman needs to understand the lack of data, and that there may indeed be toxicity from continuing the aromatase inhibitor in the way of arthritic symptoms, worsening osteoporosis, or other as-of-yet unidentified risks.

News on HER2 breast cancer vaccine?

Question from KGrimm: Anything new on the vaccine for HER2 breast cancer?

Answer —Generosa Grana, M.D., F.A.C.P.: The data that has been presented with the vaccine for HER2/neu positive disease was presented at San Antonio and was a small trial. I am not aware of any additional data in that regard. The early data from that small trial was promising, so we need to stay tuned.

Long-term cognitive side effects of treatment?

Question from MarionB: I have cognitive issues 5 years after diagnosis for breast cancer, and 4 years after treatments of chemo, radiation, tamoxifen, and Aromasin. What are the current findings regarding the long-term effects of chemo, radiation, tamoxifen, and Aromasin on cognitive deficits?

Answer —Carol Kaplan, M.D.: Unfortunately, cognitive deficits can be associated with breast cancer therapy. In patients who have received chemotherapy, this is often referred to as chemo brain. It does not look like chemotherapy has direct toxicity on the brain; rather it is likely that a combination of factors can be held responsible. These include things like sleep deprivation, estrogen deficiency, and depression amongst many other possible causes. Most patients who develop the cognitive deficits will experience some, if not total, resolution within about a year. However, unfortunately, a small subset of patients will continue to notice problems years down the road. This is not well understood, and unfortunately, no therapy has been shown to be clearly helpful for these patients. I might add that I'm not aware of any link between breast radiation and long-term cognitive deficits. So likely the chemotherapy and hormonal therapy are the culprits here. I think it would be helpful to discuss your symptoms with your oncologist so that evaluation for and treatment of things like depression and insomnia can be considered. You may find this helpful.

Screening after mastectomy and reconstruction?

Question from NGR: What is the latest advice about having a mammogram and/or ultrasound after mastectomy? I had reconstruction with tissue expanders and will have the final saline implants placed in October.

Answer —Generosa Grana, M.D., F.A.C.P.: There is no recommendation for any type of screening after a mastectomy and reconstruction, be it tissue reconstruction or expander reconstruction. In particular, when one does tissue reconstruction, if one were to do a mammogram, one could see calcifications, which are often related to fat necrosis. Finding such calcifications would lead to anxiety and further procedures that are needless. So currently, the recommendation in the setting of a mastectomy is to rely on clinical exam and to pursue imaging only when symptoms warrant it.

Heart damage due to radiation?

Question from AuntieE: I am currently going through testing for a possible heart condition. My cardiologist suspects constrictive pericarditis as a result of radiation for breast cancer. I had radiation treatment 4 years ago. What can I expect and how did this happen? I do not recall being advised that radiation therapy could damage my heart.

Answer —Generosa Grana, M.D., F.A.C.P.: First of all, the risk of radiation to the heart is quite small with new techniques and treatment planning. It would be quite unusual to develop constrictive pericarditis secondary to radiation and I would look to other etiologies, such as a viral syndrome or other. Again, the cardiac effects from radiation tend to be small and depend on whether radiation is being done post-mastectomy or post-lumpectomy and the field encompassed.

Secondary cancers from breast cancer treatment?

Question from MEdwards: Are any secondary cancers associated with the therapies for breast cancer long-term?

Answer —Carol Kaplan, M.D.: Unfortunately, there is a risk of what we call secondary cancer related to various breast cancer therapies. However, I'd like to point out that this risk is very, very low. Specifically, chemotherapy can bring with it a small risk of bone marrow cancer or leukemia years later. This is why it's important for you to discuss the benefit-to-risk ratio of your treatment with your oncologist. Additionally, tamoxifen has a well-defined but low risk of causing what is almost always an early-stage, treatable uterine cancer. Finally, radiation therapy can bring with it a risk of soft tissue tumors down the road. I'd like to say one more time, however, that cumulatively, these risks are very low.

Triple-negative breast cancer and African American women?

Question from GinaS: How much do we know about triple-negative breast cancer? Why does it hit African American women so hard? Thank you.

Answer —Generosa Grana, M.D., F.A.C.P.: We don't know very much about triple-negative disease, but there is a lot of research specifically focused on this area. We know it tends to be more aggressive in its behavior, but we don't yet have any specific target, such as the estrogen receptor or the HER2/neu receptor that can be used to alter its behavior. Why we see such a significant amount of triple-negative disease in young African American women is not at all understood. For a more in-depth discussion of this topic, please take part in the upcoming Breastcancer.org teleconference entitled Triple-Negative Breast Cancer, with Dr. George Sledge from Indiana University on July 16.

New info on prevention, treatment of lymphedema?

Question from PFamily: Was there any new information presented on the prevention or treatment of lymphedema? Thanks!

Answer —Carol Kaplan, M.D.: There is no new information that I'm aware of.

Abandon old drugs for new?

Question from CoffeeQ: It is wonderful that we keep learning more and more about this horrible disease. However, as new drugs become available, what should those of us do who are already on a drug regimen? Do we abandon the old for the new?

Answer —Generosa Grana, M.D., F.A.C.P.: I would say that the most important thing to do is to discuss your case with your treating oncologist. I would not abandon a treatment that was working, particularly in the setting of metastatic disease. There will be plenty of opportunities to try the new treatments if and when your specific treatment is no longer working. So while the research is exciting and the results of new drugs and new combinations are exciting, it is important that you work with your healthcare team to determine when these may be appropriate for you.

Chemo-induced cardiomyopathy reversible?

Question from Strnb: Have any studies been done that suggest chemo-induced cardiomyopathy is reversible?

Answer —Generosa Grana, M.D., F.A.C.P.: It depends on the type of chemotherapy that has led to the cardiomyopathy. There is good data that the cardiomyopathy related to Herceptin is very amenable to treatment, and may well be reversible in many but not all cases. The cardiotoxicity seen with anthracyclines tends to be somewhat more resistant. And there is data to suggest that it may be a bigger problem than we currently believe, particularly as women live longer and achieve older ages. So again, a lot of work is ongoing to try to predict who is at risk for cardiotoxicity with each of these specific agents and potentially to try to alter that risk.

Will breast surgery always be needed?

Question from Brenda: Do you think that treatment/s will eventually be used only and no breast tissue will have to removed?

Answer —Carol Kaplan, M.D.: It's hard to say confidently that there will ever be a time that breast surgery does not play a role in the care of a breast cancer patient. Of course, as we quickly move into the era of targeted breast cancer drugs, one can never say what might come. But I believe breast surgery is not going anywhere for the time being.

New treatments for inflammatory breast cancer?

Question from MeeshaPatel: I have inflammatory breast cancer. Any new treatments or combinations discussed at ASCO?

Answer —Generosa Grana, M.D., F.A.C.P.: Inflammatory breast cancer is a relatively uncommon presentation, but does tend to have a very specific picture and poses challenges to our management. Nothing new was presented that I am aware of, but there is a lot of interest in looking at some of the targeted agents, such as Avastin, in this setting.

Tests for risk of recurrence after 5 years?

Question from Acky: Are there any new tests for patients diagnosed over 5 years ago to understand their risk of recurrence? What about new types of tests such as hormone responsiveness, or genetic tests? Could one use her or his original cell block for these or are there any blood tests or other types of test?

Answer —Generosa Grana, M.D., F.A.C.P.: There is currently no test available that can or should be used in someone who is 5 years out from their original diagnosis to assess future prognosis. As an example, Oncotype DX is used to assess prognosis and to determine treatment, but its utility is at time of diagnosis. Things such as circulating tumor cells and other novel approaches may play a role in the future, but not at this point. So the only thing that I recommend to my patients who are at the 5-year or further point of the disease is to continue with usual surveillance and to stay positive.

Studies on hormone replacement therapy?

Question from LeQuoia: Is there any study being done on hormone replacement therapy? Or is it old news for researchers now?

Answers —Carol Kaplan, M.D.: I'm thinking you might be asking about whether hormone replacement therapy and its link to breast cancer is undergoing further evaluation. I'm not aware of any trials focusing on this at this time. However, I think that the Women's Health Initiative trial has clearly shown us an increased breast cancer risk in those patients who undergo prolonged hormone replacement therapy when it includes a combination of estrogen and progesterone agents. I think that most clinicians believe that therapy for longer than 5 years will likely bring with it an increase in the risk of breast cancer.

Generosa Grana, M.D., F.A.C.P.: A recent study was just published looking at a different issue, which is hormone replacement in breast cancer survivors. And, based on a Scandinavian trial, there was some support to the idea that hormone replacement therapy -- in that study estrogen plus progesterone -- increased risk of breast cancer recurrence. So I think the study, while not the final answer, highlights caution when giving hormone replacement or thinking about hormone replacement to women who have had breast cancer.

Bisphosphonates okay with aromatase inhibitors?

Question from Pierced: I take letrozole for early-stage breast cancer. A DEXA test showed I had lost some bone mass -- mild osteopenia. My oncologist said to wait until osteoporosis happens before starting bisphosphonates. With the Z-FAST trial and other results, do treatment guidelines now allow use of bisphosphonates to prevent osteoporosis? I am already doing everything else that is recommended.

Answer —Carol Kaplan, M.D.: I think that the use of bisphosphonates with aromatase inhibitor therapy differs between oncologists. There is no clear right answer as to what point in the spectrum of bone density loss bisphosphonate therapy should be started. The Z-FAST trial confirms the suspected belief that use of bisphosphonates can combat the bone loss associated with aromatase inhibitor therapy. I take into consideration a patient's overall health and make sure they understand the risks of bisphosphonate therapy when embarking upon a discussion about bisphosphonates with my patients. There are definitely times when I will start therapy in the osteopenia setting, but whether starting earlier versus later translates into less bone fractures is not clearly understood.

Iressa available for metastatic patients?

Question from LeapY: There was some news about gefitinib (brand name: Iressa) in the treatment of metastatic disease. Is this drug available to be prescribed to patients with metastasis who haven't had this drug yet?

Answer —Generosa Grana, M.D., F.A.C.P.: Gefitinib is an interesting drug that was thought to have great promise in a variety of cancers. It came on the market in the setting of advanced lung cancer and its activity was disappointing. It is commercially available, although I'm not sure how widely available it is because the supply has not really been supported. Despite the data presented at ASCO, I think it is a drug whose role in breast cancer is still not well defined.

Research on Evista for osteoporosis, recurrence?

Question from WRDS: I had breast cancer almost 4 years ago and have been on Arimidex for 3 1/2 years. I've developed osteoporosis due to Arimidex and Lupron injections for ovarian ablation. Has there been any research to prove the effectiveness of Evista to treat both the osteoporosis and to prevent a breast cancer recurrence in postmenopausal women who have completed the 5-year course of aromatase inhibitors?

Answer —Generosa Grana, M.D., F.A.C.P.: There is no data on Evista in the setting of breast cancer. The only data that is available, as we discussed earlier, is in women with osteoporosis and women at increased risk of breast cancer. So it is speculation to suggest that, after 5 years of an aromatase inhibitor, Evista will give you benefit in terms of recurrence. It is a drug that can be used to treat osteoporosis, but we clearly have more effective drugs in that setting. So I tend to dissuade my patients from Evista after tamoxifen use or aromatase inhibitor use because of the lack of data.

Big, positive news presented at ASCO?

Question from Marcello: Doctors, overall did you take away a general sense of positive news and advances from this ASCO meeting, whether the changes and improvements were big or small?

Answers —Carol Kaplan, M.D.: Absolutely. We are excitingly moving into an era of treating patients in a more targeted manner. Breast cancer research is moving away from treating a broad range of breast cancer patients with general anti-cancer drugs and moving towards the art of picking an individualized therapy for each subset of breast cancer, whether it be ER or PR positive or HER2 positive or associated with the BRCA mutations. Each year at ASCO, we find we're hearing yet another way to allow women to be survivors after breast cancer.

Generosa Grana, M.D., F.A.C.P.: I would absolutely agree with that. It is an incredibly exciting time to be taking care of women with breast cancer. Metastatic disease is being approached more as a chronic disease and many of the exciting findings from advanced cancer are being moved to the early-stage setting where they are likely to have a greater impact on survival. The future holds tremendous promise for breast cancer patients.

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