1. Metastatic Breast
Cancer Treatment:
State of the Art
Tanja Cufer, MD, PhD
University Clinic Golnik
Medical Faculty, Ljubljana
EORTC BCG, Chair
ESO Masterclass; Amman 2011

2. Metastatic Breast Cancer (MBC)
 The survival of pts with
5-year survival of MBC pts in
metastatic disease is Slovenia
improving
 MBC is still: 20
18
 Incurable but highly 16
treatable 14 1980-85
1986-90
 Chronic disease 12
Survival (%)
1990-95
10
 The goal of treatment: 8
1996-00
2000-05
 Control of symptoms 6
4
 Prolongation of life
2
 Good quality of life 0

3. Multidisciplinary Treatment Modalities
in MBC
 Systemic therapy
 Endocrine therapy
 Chemotherapy
 Targeted systemic therapy
 Radiotherapy (bone, CNS mets)
 Surgery (solitary lesions)
 Supportive therapy (bisphosphonates)
 Palliative medicine

4. 1st main question:
Optimal systemic therapy in first-
line treatment?

5. Tailoring Systemic Therapy in MBC
 Disease-related factors
 Biology of disease
 ER/PR status
 HER2 status
 Proliferation
 Disease-free interval
 Tumor burden (number & site of mets)
 Need for rapid disease control
 Previous systemic therapy
 Patient-related factors
 PS
 Age
 Co-morbidities
 Patient’s preferences

6. Individualized Treatment Selection
HER2 Endocrine responsive Endocrine non-responsive
(HR+, long DFI, soft (HR-/uncertain, short DFI,
ER tissue/bone mets) visceral mets)
HER2- ET CT
negative
HER2- positive HER2 directed + ET HER2-directed + CT
Thargeted therapies comes first!

7. 2nd main question:
Repeating ER/PR and HER2 status at
the time of progression?

8. ASCO 2010: Significant Rate of Discordance
Between Primary and Metastases
#1007 #CRA 1008 #1009
Studies Amir et al. Locatelli et al. Karlsson et al.
N=271 N=255 N=477
prospective retrospective retrospective
(liver)
Would you deny a(12%) 22/197 (11%) 123/336 (36%)
ER+ primary with loss in recurrence 21/174 patient a targeted
ER- primary with gain in recurrence 8/57 (14%) 15/58 (25%) 32/141 (22%)
treatment due to changes in the 32%
Overall ER discordance rate 12% 14.5%
Overall PR discordance ratemetastatic site? 48%
34% 43%
HER2- primary with gain in recurrence 9/197 (4.6%) 7/118 (5.9%) n.d.
HER2+ primary with loss in recurrence 3/24 (12.5%) 17/54 (31.5%) n.d.
Change in management from results of 15% 12% n.d.
recurrence biopsy
Discussion ASCO 2010: Richardson AL

9. Endocrine Therapy for MBC
 Premenopausal patients
 Tamoxifen
 OAS
 OAS +Tamoxifen
 OAS + AI
 Postmenopausal patients
 Als
 Tamoxifen
 Fulvestrant

10. Combined Tamoxifen and LHRH Agonist vs LHRH
Agonist Alone in Premenopausal Advanced Breast
Cancer: A Meta-Analysis of Four Randomized Trials
End Point LHRH agonist LHRH agonist HR 95%CI p
alone + Tamoxifen
N=256 N=250
Median survival, years 2.5 2.9 0.78 0.63-0.96 0.02
Median PFS, months 5.4 8.7 0.70 0.58-0.85 0.0003
Objective response % 29.7 38.8 0.67 0.46-0.96 0.03
LHRH+TAM
LHRH
Klijn, et al. J Clin Oncol 2000;19.

11. Randomized Phase III Trials of AIs vs.
Tamoxifen as First-line Treatment of
Postmenopausal MBC
Anastrozole1 Anastrozole2 Letrozole3 Exemestane4
No. patients 170 vs 182 340 vs 328 453 vs 454 182 vs 189
ORR, % 21 vs 17 33 vs 33 32 vs 21* 46 vs 31*
CBR, % 59 vs 46* 56 vs 56 50 vs 38* 66 vs 49*
TTP or PFS, months 11 vs 6* 8 vs 8 9 vs 6* 10 vs 6*
ER status unknown, % 11 vs 11 56 vs 54 34 vs 33 15 vs 11
ORR = overall response rate; CBR = clinical benefit rate; TTP = time to progression; PFS = progression free survival; ER = estrogen receptor
*Statistically significant difference
1. Nabholtz JM, et al. J Clin Oncol. 2000;18 2. Bonneterre J, et al. J Clin Oncol. 2000;18
3. Mouridsen H, et al. J Clin Oncol. 2003;21 4. Paridaens R, et al. J Clin Oncol. 2008;26

12. Hormonal Therapy in Postmenopausal
MBC: Aromatase Inhibitors
 All three AIs showed higher RR and longer TTP compared to
Tam in first line setting; no differences in long term OS
(Mouridsen et al JCO 2003; Bonneterre et al Cancer 2001,
Paridaens et al, ASCO 2004);
 All three AIs seem to be equally effective with slight
differences in untoward effects (Rose et al ASCO 2002,
Cameron et al , ASCO 2004, Mayordomo et al, ASCO 2006)
 The efficacy of AIs after Tam is comparable to the efficacy of Tam
after AIs (Thurlimann et al, EJCancer 2003)
 Steroid inactivator exemestane is effective after failure to
nonsteroidal AIs, nonsteroidal AIs are effective after failure to
exemestane (Thurlimann et al, EJCancer 1997, Bertelli G, et al.
Oncology. 2005)

13. FIRST: Fulvestrant 500 mg vs. Anastrozole
as First-Line
1.0
Proportion of patients alive
and progression-free
0.8 Fulvestrant 500 mg
Anastrozole 1 mg
0.6
0.4
0.2 HR = 0.66 (95% CI: 0.47-0.92)
P = .01
0.0
0 6 12 18 24 30 36 42 48
Time (months)
Number of patients at risk:
Fulvestrant 500 mg 102 74 65 52 45 34 20 6 0
Anastrozole 1 mg 103 69 55 39 30 21 8 2 0
CI = confidence interval; HR = hazard ratio; TTP = time to progression
Robertson JF, et al. Cancer Res. 2010;70: Abstract S1-3.

14. How to Overcome Resistance to ET ?
 mTORC1 activates ER in a
ligand-independent fashion1
 Estradiol suppresses
apoptosis induced by
PI3K/mTOR blockade2
 Hyperactivation of the
PI3K/mTOR pathway is
observed in endocrine-
resistant breast cancer cells3
 mTOR is a rational target to
enhance the efficacy of
hormonal therapy
1. Bjornsti MA, et al. Nat Rev Cancer. 2004;4(5):335-348. 2. Crespo JL, et al. Microbiol Mol Biol Rev. 2002;66(4):579-591.
3. Huang S, et al. Cancer Biol Ther. 2003;2(3):222-232. 4. Mita MM, et al. Clin Breast Cancer. 2003;4(2):126-137.
5. Wullschleger S, et al. Cell. 2006;124(3):471-484. 6. Johnston SR. Clin Cancer Res. 2005;11(2 Pt 2):889S-899S.

15. TAMRAD: Tamoxifen +/- Everolimus as
Second- Line After AIs Failure
1.0
0.9
Probability of survival
0.8
0.7
0.6
0.5
0.4 TAM
TAM + RAD
0.3
0.2 Hazard Ratio (HR) = 0.32 (95% CI: 0.15-0.68)
Exploratory log-rank: P = .0019
0.1
0.0
0 3 6 9 12 15 18 21 24 27 30 33 36
Months
Patients at risk:
TAM + RAD: n = 54 53 51 49 49 45 38 26 14 6 0
TAM: n = 57 55 53 50 44 38 30 22 9 4 0
CI = confidence interval; HR = hazard ratio; RAD = RAD001; TAM = tamoxifen
Bachelot T, et al. Cancer Res. 2010;70: Abstract S1-6.

16. BOLERO-2: Exemestane +/- Everolimus
in AI Refractory Disese
N = 724
Everolimus 10 mg/day + PFS
Exemestane 25 mg/day
Postmenopausal (N = 485)
2 OS
ER+ HER2- ABC
ORR
refractory to
1 Bone Markers
letrozole or Placebo + Safety
anastrozole Exemestane 25 mg/day PK
(N = 239)
 Stratification:
 Sensitivity to prior hormonal therapy
 Presence of visceral disease
 No crossover
ABC: advanced breast cancer, NSAI: non steroidal aromatase inhibitors, HER2-: human epidermal growth factor receptor 2 – negative;
PFS: progression-free survival; PK: pharmacokinetics
Baselga J, et al. Eur J Cancer Suppl. 2011;47(Suppl 2): Abstract: 9LBA.

17. BOLERO-2 Primary Endpoint: PFS
Local Assessment
HR = 0.43 (95% CI: 0.35–0.54)
100
Log rank P value = 1.4 x 10 -15
80 EVE + EXE: 6.9 months
Probability of Event, %
PBO + EXE: 2.8 months
60
40
20
Everolimus + Exemestane (E/N = 202/485)
Placebo + Exemestane (E/N = 157/239)
0
0 6 12 18 24 30 36 42 48 54 60 66 72 78
Time, weeks
No. of Patients Still at Risk:
Everolimus 485 398 294 212 144 108 75 51 34 18 8 3 3 0
Placebo 239 177 109 70 36 26 16 14 9 4 3 1 0 0
Baselga J, et al. Eur J Cancer Suppl. 2011;47(Suppl 2): Abstract: 9LBA.

18. Chemotherapy for MBC
Combination Chemotherapy or Sequential Use of
Monotherapy?
 Most trials and meta-analysis compare single agent vs.
combination and NOT sequential use of single agents
vs. combination CT.
 The majority of trials show that combination CT yields
higher RR, in some higher PFS, higher toxicity and no or
quite small survival benefit.

19. Chemotherpy Agents = Survival Gains
Pooled analysis of 6 consecutive trials of first-line CT in MBC:
- Clear evidence of an increase in OS during the past 20 years,
starting with the inclusion of paclitaxel
100
90
80
1998-2001
70 Median OS
Probability %
1995-1997
60 1992-1994 - 18.0 mos, in 1983-1986
50
1987-1989 - 17.2 mos, in 1987-1989
1983-1986
40
- 19.2 mos, in 1992-1994
30
- 26.1 mos, in 1995-1997
- 23.6 mos, in 1998-2001 cohorts
20
(P for heterogeneity .0001)
10
0
0 1 2 3 4 5 6 7 8
Years
CT, chemotherapy; OS, overall survival
Gennari A, et al. Cancer. 2005;104(8):1742-1750.

20. Randomized Studies with Crossover Following
in the Monotherapy Arm
Time to Overall
Author Comparison Number of Response Rate Progression Survival
Year (x number of cycles) patients (%) (months) (months)
Alba A x 3 Doc x 3 144 61 10.5 22.3
2004 A + Doc x 6 51 9.2 21.8
Beslija Doc  X 100 40 7.7 19.0
2006 Doc + X 68* 9.3* 22.0*
Conte E x 4  Pac x 4 202 58 10.8‡ 26.0
2004 E + Pac x 8 58 11.0‡ 20.0
Koroleva Doc x 4  A x 4 193 56 6.9 13.8
2001 A + Doc x 8 49 6.7 11.9
A + Doc║ x 8 59 8.3 14.5
Sjöstrom Doc 238 42* 6.3* 10.4
1999 MF 21 3.0 11.1
Sledge A 739 36 5.8¶ 18.9
2003 Pac 34 6.0¶ 22.2
A + Pac 47* 8.0*¶ 22.0
Soto X  Pac or Doc 368 45 8.4‡ 31.5
2006 X + Pac 64* 6.7‡ 33.1
X + Doc 75* 8.1‡ 28.5
Tomova Doc x 4 G x 4 100 28 6.7 15.9
2008 Doc + G x 8 31 7.0 15.5
*Denotes statistically significant result with P≤.05
Cardoso F, et al. J Natl Cancer Inst. 2009;101(17):1174-1181

21. COMBINATION SEQUENTIAL SINGLE AGENTS
>RR Similar survival ! <Toxicity
Faster symptom/disease control Better overall QoL
Better management of resources

22. New Cytotoxic Agents
 New cytotoxic agents
 Targeting microtubules: Eribulin, Epothilones
 “Old” agents in new formulations
 Capecitabine (considered standard in A&T pretreated pts)
 Liposomal anthracyclines
 New formulations of anti-microtubules: albumin bound, nab-
paclitaxel
 “Old” agents in new indications
 Platinum & Alkylating agents for TN

23. EMBRACE: A Phase III Study of Eribulin in
Heavily Pre-treated pts: Overall Survival (ITT)
1.0
1-Year Survival
Eribulin (n = 508) 53.9%
0.8 TPC (n = 254) 43.7%
Survival Probability
Eribulin
median 13.12 months
0.6
TPC HR* 0.81 (95% CI: 0.66, 0.99)
0.4 median 10.65 months P value† = 0.041
0.2
2.47 months
0.0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Overall Survival, months
Twelves C, et al. J Clin Oncol. 2010;28(15s): Abstract CRA1004.

24. What is the optimal duration of
chemotherapy ?

25. U1
Results: Progression Free Survival
Optimal Duration of Study Longer better Shorter better %Weight HR 95%CI
Coates 1987 13 0.56 0.44-0.71
Chemotherapy? Harris 1990
Muss 1991
2
3
1.18
0.26
0.65-2.15
0.16-0.43
Ejlertsen 1993 28 0.71 0.61-0.83
Gregory 1997 10 0.70 0.53-0.92
Falkson 1998 5 0.46 0.31-0.68
Bastit 2000 11 0.65 0.50-0.84
Nooij 2003 8 0.67 0.50-0.90
Gennari 2006 6 1.01 0.71-1.43
Majordomo 2009 8 0.77 0.57-1.05
Alba 2010 6 0.53 0.37-0.76
Overall 100 0.64
0.66 0.55-0.76
0.60-0.72
U1 0.10 1.00 10.00
Results: Overall Survival Test for heterogeneity, p=0.001 Test for treatment effect, p<0.001
Study Longer better Shorter better %Weight HR 95%CI
Coates 1987 13 0.79 0.62-1.01
Harris 1990
Muss 1991
2
5
1.06
1.11
0.57-1.97
0.74-1.67
 Longer CT duration:
Ejlertsen 1993
Gregory 1997
17
5
0.78
0.81
0.63-0.97
0.54-1.21
 36% reduction in the risk of
Falkson 1998 8 0.94 0.69-1.28 progression (HR 0.64; 95%
Bastit 2000
Nooij 2003
18
17
0.96
1.03
0.78-1.18
0.83-1.27
CI 0.55 – 0.76)
Gennari 2006
Majordomo 2009
4
7
1.12
0.94
0.73-1.72
0.67-1.32
 9% reduction in the risk of
Alba 2010 5 0.86 0.58-1.27 death (HR 0.91; 95% CI 0.84-
Overall
0.10 1.00 10.00
100 0.91 0.84-0.99
0.99)
Test for heterogeneity, p=0.69 Test for treatment effect, p=0.044
25
Gennari et al, ESMO 2010

26. Targeted Therapies in MBC
 HER2-directed therapy (considered standard
in HER2+ disease)
 PARP inhibitors
 Antiangiogenic agents

27. Anti-HER2 Therapy in Combination with
Chemotherapy in HER2-Positive MBC
TTP OS
Trial Treatment ORR (%)
(months) (months)
Slamon et al.1; Trastuzumab + 7.1 vs. 25.1 vs.
49 vs. 17*
Smith et al. 2 paclitaxel vs. paclitaxel 3.0* 18.0*
Trastuzumab + 11.7 vs. 31.2 vs.
Marty et al.3 61 vs. 34*
6.1* 22.7*
docetaxel vs. docetaxel
Di Leo et al. 4
Lapatinib + paclitaxel 8.5 vs. 24.0 vs.
(ErbB2+ 63 vs. 38*
vs. paclitaxel 5.8* 19.8*
patients only)
Lapatinib + paclitaxel 9.7 vs. 27.8
Guan et al. 5 69 vs. 50*
6.5* vs.20.5*
vs. Paclitaxel
*= statistically significant
1. Slamon et al. N Engl J Med 2001;344, 2. Smith et al. Anticancer Drugs 2001;12 Suppl 4:S3–10, 3. Marty et al. J
Clin Oncol 2005;23, 4. Di Leo et al. Clin Oncol 2008;26, 5. Guan et al. 33rd SABCS 2010; Abstract P3-14-24

28. First-line Treatment with Trastuzumab +
Docetaxel or Vinorelbine in ErbB2+ MBC:
HERNATA Study
Anderssen M, et al. J Clin Oncol 2011;29

29. Anti-HER2 Therapy in Combination with
Endocrine Therapy in ER+/HER2+ MBC
 Anastrozole + Trastuzumab (TANDEM)1
 CB 28 v 43%; PFS 2.4 v 4.8 months

 Letrozole + Lapatinib (EGF30008)2
 CB 29 v 48%; PFS 3.0 v 8.2 months
1. Kaufman, et al. J Clin Oncol 27 2009, 2. Johnston, et al. J Clin Oncol 27 2009,

30. TANDEM: Evaluation of Anastrozole +/-
Trastuzumab in HER2+/HR+ MBC
100 A A+H
Outcome P Value
(n = 104) (n = 103)
Progression-Free
80 Events, n 99 87
Survival (%)
60 Median PFS, mos
2.4 (2.0-4.6) 4.8 (3.7-7.0) .0016
(95% CI)
40
20
0
0 5 10 15 20 25 30 35 40 45 50 55 60
2.4 months Months
A+H n = 103 48 31 17 14 13 11 9 4 1 1 0 0
A n = 104 36 22 9 5 4 2 1 0 0 0 0 0
Kaufman, et al. J Clin Oncol 2009.

31. TANDEM: Evaluation of Anastrozole +/-
Trastuzumab in HER2+/HR+ MBC
Anastrozole
N=207
Anastrozole +
Median age 55 years Trastuzumab
Visceral disease 1/3
Prior chemo 1/2
Cross-over 70%
6,8% Response rate 20,3%
p 0.0016
2,4m Median PFS. 4,8m
23,9m Median O.S. 28,5m
32,1m Median O.S. 41,9m
if no liver mets p 0.03
Trastuzumb added to anastrozole  RR, PFS (and possibly OS if no liver mets)
IMPORTANCE OF STARTING BIOLOGICAL AGENT SOON
Mackey, et al. SABC 06;abst.03. Adapted from M. Piccart

32. Current Evidence Based Options of Anti-
HER2 Treatment Beyond Trastuzumab
Progression (Phase III trials)
 Continuing trastuzumab (GBG 26 / BIG 3-05
study)
 Lapatinib + capecitabine (EGF100151 study)
 Lapatinib + trastuzumab (EGF104966 study)

33. Comparison of Three Prospective Phase III
Trials on Anti-HER2 Treatment Beyond
Trastuzumab Progression
GBG-26a EGF100151b EGF104900a
(n=156) (n=399) (n=296)
Regimen XH X XL X LH L
ORR, % 48 27 32 17 10 7
TTPc
HR 0.69 (p=0.03) 0.72 (p=0.01) 0.73 (p=0.01)
Median, 8.2 5.6 5.5 4.2 2.8 1.9
months
OS
HR 0.76 (p=0.26) 0.78 (p=0.18) 0.74 (p=0.02)
Median, 25.5 20.4 15.6 15.3 14.0 9.5
months
aVon Minckwitz et al 2008; O’Shaughnessy et al 2008;
bInvestigator Assessment, US Lapatinib Prescribing Information & Cameron et al 2008;

34. New HER2-directed Agents
 Pertuzumab (first-in-class ErbB dimerisation inhibitor)
 Phase 2 trials completed, undergoing phase 3 in combination with
trastuzumab (CLEOPATRA trial)
 Neratinib (oral, pan-ErbB TKI)
 Phase 2 trials in monotherapy and in combination with paclitaxel or
vinorelbine completed, undergoing phase III combination trial with
paclitaxel (NEFERTT trial)
 Afatinib (oral irreversible ErbB1 and 2 inhibitor)
 Phase III trial in combination with vinorelbine (Lux-Breast1)
 Trastuzumab - DM1 (HER2-targeted antibody-drug
conjugate)
 In phase2 trial comperable efficacy with better toxicity profile
compared to trastuzumab and docetaxel
 Ongoing phase 3 trials

35. TDM4450g : Progression-Free Survival
Median Hazard Log-rank
PFS, mos ratio 95% CI P value
Trastuzumab
1.0
+ docetaxel (n=70) 9.2 0.364–
0.594 .0353
Proportion Progression-Free
T-DM1 (n=67) 14.2 0.968
0.8
0.6
0.4
0.2
0.0
0 2 4 6 8 10 12 14 16 18 20
Time, months
Number of patients at risk
T+D 70 66 63 53 43 27 12 4 2 2 0
T-DM1 67 60 51 46 42 35 22 15 6 3 0
Hazard ratio and log-rank P value were from stratified analysis.
Hurvitz S, et al. Eur J Cancer Suppl. 2011;47(Suppl 2): Abstract 5001.

36. Biological agents for HER-2
negative disease

37. Bevacizumab: First-Line MBC Meta
Analysis
E2100
Paclitaxel
RANDOMIZE
Chemo + Optional
Previously Treat Second-line
AVADO No BV
Untreated Chemo + BV
Docetaxel until (AVADO and
MBC Chemo + PD RIBBON-1
BV only)
RIBBON-1
Capecitabine,
Taxane,
or
Anthracycline
O’Shaugnessy J, et al. J Clin Oncol. 2010;28(15S): Abstract 1005.

38. Bevacizumab in MBC
RIBBON-1:
E21001 AVADO2 Capecitabine3 RIBBON-1: A/T3
Placebo (Pl) controlled No Yes Yes Yes
q 3 wk
Weekly
Chemotherapy q 3 wk docetaxel (D) Capecitabine (C) docetaxel/nabPAC/FA
paclitaxel (P)
C/EC/FEC
10 mg/kg 7.5 or 15 mg/kg 15 mg/kg 15 mg/kg
Dose of bevacizumab (B)
q 2 wk q 3 wk q 3 wk q 3 wk
P P+B D+PI D+B C+PI C+B A/T+PI A/T+B
ORR 25% 49% 49% 55%/63% 24% 35% 38% 51%
PFS, months 5.9 11.8 80 8.7/8.8 5.7 8.6 8.0 9.2
0.79 (7.5 mg)
0.60 P = .0318 0.69 0.64
HR
P<.0001 0.72 (15 mg) P = .0002 P<.0001
P = .0099
OS, months 25.2 26.7 NR NR 21.2 29 23.8 25.2
0.88 0.92 (7.5 mg) 0.85 1.03
HR
P = .16 0.86 (15 mg) P = .27 P = .83
Meta-Analysis (O’Shaughnessy et al ASCO 2010)
PFS: 2.5 months, OS: 0.3 months
1.Miller K, et al. N Eng J Med. 2007;357(26), 2. Miles D, et al. J Clin Oncol. 2008;26:(May 20 Suppl): Abstract
LBA1011, 3. Robert NJ, et al. J Clin Oncol. 2009;27(15S): Abstract 1005.

39. Multi-center, Randomized Open-label Phase
III RegistrationNTrial of Iniparib in mTNBC
= 519
Patient Population:
 mTNBC Gem/Carbo (GC) Crossover allowed
 0–2 prior chemo for (N= 258)
metastatic TNBC to GCI following
Gemcitabine 1000 mg/m2 IV d 1, 8 Disease Progression*
 Stable CNS metastases Carboplatin AUC2 IV d 1, 8 (central review)
allowed
21-day cycles
Stratification: R
 No prior chemo vs 1–2 Gem/Carbo + Iniparib (GCI)
prior chemo for mTNBC
(N= 261)
Gemcitabine - 1000 mg/m2 IV d 1, 8
Carboplatin - AUC2 IV d 1, 8
Endpoints: Iniparib - 5.6 mg/kg IV d 1,4,8,11
 Primary: OS, PFS
21-day cycles
 Secondary: ORR,
safety/tolerability
96% (n=152) of progressing patients crossed over to GCI at time of primary analysis
O’Shaughnessy et al, ASCO 2011

40. Efficacy Endpoints – ITT Population
GC* GCI GC GCI
PFS OS
(N=258) (N=261) (N=258) (N=261)
Median PFS, mos 4.1 5.1 Median OS, mos 11.1 11.8
(95% CI) (3.1, 4.6) (4.2, 5.8) (95% CI) (9.2, 12.1) (10.6, 12.9)
HR (95% CI) 0.79 (0.65, 0.98) HR (95% CI) 0.88 (0.69, 1.12)
1.0 p-value 0.027 1.0 p-value 0.28
Probability of Progression Free Survival
0.9 0.9
0.8 0.8
Probability of Survival
0.7 Pre-specified alpha = 0.01
0.7 Pre-specified alpha = 0.04
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0
0 2 4 6 8 10 12 14 16 0 2 4 6 8 10 12 14 16
Months Since Study Entry Months
No. at risk No. at risk
GC 258 171 116 63 38 18 6 1 0 GC 258 239 214 181 151 99 38 11 0
GCI 261 187 138 83 53 11 2 0 0 GCI 261 248 230 204 169 111 52 15 0
O’Shaughnessy et al, ASCO 2011

41. Potential Solutions to Improve MBC
Outcome
 New treatments
 New strategies with “old” treatments
 More pts in clinical trials
Less than 5-10% of cancer patients participate in
clinical trials in the western countries!!
 Biomarkers (predictive, pharmacogenetics,
pharmacogenomics…)
 International RECOMMENDATIONS (that are
followed!) (implementation of recommendations
such as St Gallen increased survival EBC)

42. The “St Gallen” of MBC
PLEASE JOIN US!!