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. 2020 Jun 8:6:21.
doi: 10.1038/s41523-020-0168-9. eCollection 2020.

Evidence-based guidelines for managing patients with primary ER+ HER2- breast cancer deferred from surgery due to the COVID-19 pandemic

Mitch Dowsett  1   2 , Matthew J Ellis  3   4   5 , J Michael Dixon  6 , Oleg Gluz  7   8   9 , John Robertson  10 , Ronald Kates  11 , Vera J Suman  12 , Arran K Turnbull  13 , Ulrike Nitz  7 , Matthias Christgen  14 , Hans Kreipe  14 , Sherko Kuemmel  15 , Judith M Bliss  16 , Peter Barry  17 , Stephen R Johnston  17 , Samuel A Jacobs  18 , Cynthia X Ma  19 , Ian E Smith  17 , Nadia Harbeck  11   20
Affiliations

Evidence-based guidelines for managing patients with primary ER+ HER2- breast cancer deferred from surgery due to the COVID-19 pandemic

Mitch Dowsett et al. NPJ Breast Cancer. .

Abstract

Many patients with ER+ HER2- primary breast cancer are being deferred from surgery to neoadjuvant endocrine therapy (NeoET) during the COVID-19 pandemic. We have collated data from multiple international trials of presurgical endocrine therapy in order to provide guidance on the identification of patients who may have insufficiently endocrine-sensitive tumors and should be prioritised for early surgery or neoadjuvant chemotherapy rather than NeoET during or in the aftermath of the COVID-19 pandemic for safety or when surgical activity needs to be prioritized. For postmenopausal patients, our data provide strong support for the use of ER and PgR status at diagnosis for triaging of patients into three groups in which (taking into account clinical factors): (i) NeoET is likely to be inappropriate (Allred ER <6 or ER 6 and PgR <6) (ii) a biopsy for Ki67 analysis (on-treatment Ki67) could be considered after 2-4 weeks of NeoET (a: ER 7 or 8 and PgR <6 or b: ER 6 or 7 and PgR ≥6) or (iii) NeoET is an acceptable course of action (ER 8 and PgR ≥6). Cut-offs for percentage of cells positive are also given. For group (ii), a high early on-treatment level of Ki67 (>10%) indicates a higher priority for early surgery. Too few data were available for premenopausal patients to provide a similar treatment algorithm. These guidelines should be helpful for managing patients with early ER+ HER2- breast cancer during and in the aftermath of the COVID-19 crisis.

Keywords: Breast cancer.

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Conflict of interest statement

Competing interestsM.D. is on advisory board in Lilly, H3Biomedicine, AbbVie, Orion and consultancy: Radius; Honoraria for lectures: Nanostring, Myriad. M.J.E. reports ownership and income from Veracyte/Nanostring for Royalties for Prosigna and ad hoc consulting fees from Novartis, Pfizer, AstraZenica, GI therapeutics, Foundation Medicine, Sermonix, Abbvie. O.G. has Lecture/consultancy fees from Celgene, Roche, Genomic Health, Amgen, Pfizer, Novartis, Lilly, Nanostring, Eisai, MSD; assistance with travel costs: Celgene, Roche, Daiichi Sankyo; S.K. reports personal fees from Roche/Genentech, Genomic Health, Novartis, Amgen, Celgene, Daiichi Sankyo, AstraZeneca, Somatex, MSD, Pfizer, Puma Biotechnology, PFM Medical, Lilly, Sonoscape. C.X.M. reports research funding from Pfizer, consulting fees from AstraZeneca, Novartis, Eli Lilly, Seattle Genetics, and Athenex Oncology. N.H. reports personal fees (lectures / consulting) from Agendia, Amgen, Astra Zeneca, BMS, Celgene, Daiichi-Sankyo, Genomic Health, Lilly, MSD, Novartis, Odonate, Pierre Fabre, Pfizer, Roche, Sandoz/Hexal, Seattle Genetics. The remaining authors declare no conflict of interests.

Figures

Fig. 1
Fig. 1. Flowcharts to show use of ER and PgR categories and on-NeoET Ki67 for directing postmenopausal patients with primary ER + HER2-breast cancer towards NeoET or surgery/neoadjuvant chemotherapy based on Allred scores or based on % cells positive.
Allred scores are created by summing two separate scores: (the overall intensity of stained cells, none = 0, weak = 1, intermediate = 2, strong = 3) + (percentage of cells staining positive none = 0, <1% = 1, 1–10% = 2, 11–33% = 3, 34–66% = 4, ≥67% = 5).
See this image and copyright information in PMC

References

    1. Dietz J. R. et al. Recommendations for prioritization, treatment, and triage of breast cancer patients during the COVID-19 pandemic. the COVID-19 pandemic breast cancer consortium. Breast Cancer Res Treat, 181, 487–497 (2020). - PMC - PubMed
    1. Martí C, Sánchez-Méndez JI. Neoadjuvant endocrine therapy for luminal breast cancer treatment: a first-choice alternative in times of crisis such as the COVID-19 pandemic. ecancer. 2020;14:1027. doi: 10.3332/ecancer.2020.1027. - DOI - PMC - PubMed
    1. Miller WR, Dixon JM, Macfarlane L, Cameron D, Anderson TJ. Pathological features of breast cancer response following neoadjuvant treatment with either letrozole or tamoxifen. Eur. J. Cancer. 2003;39:462–468. doi: 10.1016/S0959-8049(02)00600-7. - DOI - PubMed
    1. Low SC, et al. Tumour oestrogen receptor content allows selection of elderly patients with breast cancer for conservative tamoxifen treatment. Br. J. Surg. 1992;79:1314–1316. doi: 10.1002/bjs.1800791224. - DOI - PubMed
    1. Dowsett M, et al. Endocrine therapy, new biologicals, and new study designs for presurgical studies in breast cancer. J. Natl Cancer Inst. Monogr. 2011;2011:120–123. doi: 10.1093/jncimonographs/lgr034. - DOI - PubMed