The guidelines are mostly western and in many scenarios, it is difficult to apply them to Indian population. We need to take in to consideration many factors while applying the data

1. How to effectively incorporate data
to diagnose, stage and treat breast
cancer
Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist)
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow

2.  Discussion thoughts to go on:
 Western versus Indian breast cancer patients
 Western versus indigenous data
 Consensus Indian guideline
 Availability of changing data
 Use of online tools
 Some case discussion
Incorporating Data

3. Indian breast cancer patients
versus western population

4. 5-Year age distribution of breast
cancer patients from registry data

5.  Disease peaks at 40-50 years of age
 Higher incidence of triple negative breast cancers
 Genomic variations
 Advanced stage at presentation: 50% in stage III-
IV
 Access to screening, diagnostic and treatment
facilities
Indian versus western patients

6.  Patient population different
 Tolerance to systemic
chemotherapy/treatments different
 Access to quality healthcare
 Management of acute and late complications
 Optimization of resources
 Cost-effectiveness
Western data vs Indian data

7. Indian guidelines!!

9.  New Phase III trial demonstrating an improvement of survival
with change in practice recommendations presented at a
prestigious meeting
 Full paper publication
 Center: Single vs multi-institutional
 Indian patients %
 Wait for more data: Trigger line for changing practice
 Society recommendations: which one to follow?
 ASCO, ESMO, NCCN, NICE, ASTRO etc.
 Reading between the lines
Application of an emerging data
on practice

10.  Evidence based versus experience-based
practice: Self bias
 Retrospective evaluation of own practice
 Clinical trials at own center
 Multi-institutional collaborations
 Medico-legal implications
 Peer pressure
 Administrative issues
 Cost and availability
Application of an emerging data
on practice

11.  Use in your practice
 Change in decisions based on the risk calculators
 Which patients and what decisions
 Tools available:
 Breast cancer risk assessment tools: NCI
 PREDICT survival rates after surgery: NHS
 Adjuvant Online: Benefits of adjuvant therapy
Online tools to facilitate practice

12. Online tools to facilitate practice

13. Online tools to facilitate practice

14. Slide 1

15. Slide 2

16. Conflicting results with adjuvant capecitabine
GEICAM: However, a prespecified subgroup analysis showed a significant
survival benefit with capecitabine among patients with non–basal-like triple-
negative breast cancer (ie, IHC-negative for EGFR and CK5/6). Among this
subgroup, 5-year disease-free survival was 82.6% with capecitabine vs 72.9%
with observation—a significant 47% improvement (P = .02).

17. Slide 5

20. Slide 18

21. Slide 19

22. The SOFT trial

23. Summary – SOFT Trial
SOFT Tamoxifen-
OFS
Tamoxifen P value
5-yr DFS 86.6% 84.7% 0.10
5-yr OS 96.7% 95.1% 0.13
5-yr BC
freedom rate
88.4% 86.4% 0.09
949 premenopausal women (>40 years of age, small,
node-negative tumors, low to intermediate
Grade)
Freedom from recurrence > 95% at 5 years with TAM
alone

24.  Most recurrences of
breast cancer were in
patients who remained
premenopausal after
receiving chemo.

27. TEXT-SOFT combined
analysis
Tamoxifen-
OFS
Exemestane-
OFS
P-value
5-yr DFS 87.3% 91.1% P<0.001
5-yr BC free interval 88.8% 92.8% P<0.001
Freedom from
recurrence of breast
cancer at a distant site
92% 93.8% P=0.02
5-yr OS 95.9% 96.9% p=0.37
• Median follow-up : 68 months
Among patients who received chemotherapy, the absolute improvement in the 5-
year BC-free rate with Exemestane-OFS as compared with tamoxifen- OFS was
5.5% in TEXT and 3.9% in SOFT.

28.  Short follow up: 5 years in 15 years disease
 Endpoints: DFS vs. OS
 Late switch to AI after 5 years of TAM vs.
OFS+AI [Improved DFS in MA.17]
 Therapy after 5 years of OFS+AI unknown

29. Questions unanswered??
 Role of OFS in patients receiving 10 years of TAM or TAM+AIs
 Role of OFS versus Chemotherapy
 Should all patients who remain premenopausal after adjuvant
chemotherapy receive OFS?
Adjuvant Ovarian Suppression plus AI or
Tamoxifen (ASPAIT)
Sun yat sen University (Recruiting)
Neoadjuvant Aromatase Inhibitor(AI)
With Ovarian Suppression Versus
Chemotherapy in Premenopausal Breast
Cancer Patients (COMPETE)
Li Zhu, Rujin Hospital (China)
Evaluating the Role of the Addition of
Ovarian Function Suppression (OFS) to
Tamoxifen in Young Women (ASTRRA)
Korean breast cancer study group

30. Age <35 years
Those who remained premenopausal after chemotherapy
Large/ node-positive tumors, higher-grade tumour features.

31. Slide 23

32. The Biology
Of The
Patient
Integrating / Presenting Information
Decision
The Biology Of The
Tumor
Treatment
Efficacy /
Toxicity
Doctor’s
Opinions
Patient’s
Opinions