Expert Point of View: Kathy S. ­Albain, MD, FACP, FASCO, and Jame Abraham, MD


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Jame Abraham, MD

It is reassuring that TCH yields similar 10-year outcomes to AC-T, even for patients with many positive lymph nodes.

—Kathy S. Albain, MD, FACP, FASCO

The general consensus of breast cancer experts of the initial findings of BCIRG-006 triggered a more judicious use of anthracyclines, and this trend continues. Kathy S. ­Albain, MD, FACP, FASCO, Professor of Medicine at Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, said that much could be derived from the final analysis of BCIRG-006.

“I think the best contribution from this update is that the results provide reassurance for women and their oncologists who choose nonanthracycline-based trastuzumab-containing treatment…. The 10-year outcomes are excellent,” she said.

Dr. Albain considers that both types of regimens—those with and those without anthracyclines—are excellent options for most patients. “There was a numerical difference between AC-TH and TCH, but it was not significant for superiority with anthracyclines,” she noted. “Of particular importance is that in the higher risk node-positive subset—even those with four or more positive nodes—both trastuzumab [Herceptin] arms have very similar long-term survival outcomes.”

She acknowledged that many breast cancer experts have always perceived “a slight advantage” for AC-TH in the disease-free survival curve, “but these updated data seem to dispel these concerns. For the very fit patient with very high-risk disease, you may still want to consider an anthracycline-based regimen,” she added, “given that lingering numerical advantage, since we will never have a trial done that compares these two regimens only in women with many positive nodes.” For the rest, she concluded, “there is much more reassurance with this update that the long-term outcomes are excellent for TCH and the toxicity profile is favorable.”

Further Comments

Jame Abraham, MD, Director of the Breast Oncology Program at the Taussig Cancer Institute, Cleveland Clinic, Ohio, said BCIRG-006 is extremely important for several reasons. “When the results were initially presented, we saw greater numerical differences between the arms,” he noted. “Now we know that only 10 events separate AC-TH from TCH. We know there’s no difference—that disease-free and overall survival are basically the same with these two regimens.”

However, added Dr. Abraham, the differences in toxicity are also important. “Cardiac problems and leukemia are much less with TCH.”

In his practice, Dr. Abraham prefers to give his very low–risk HER2-positive patients weekly paclitaxel plus trastuzumab. For moderate-risk (one to four positive nodes) patients, he recommends TCH. For some very high–risk patients (more than eight to nine positive nodes), he may continue to use AC-TH.

“The data tell me that it is very reasonable to use TCH, even in the fairly high-risk patients,” he added. ■

Disclosure: Drs. Albain and Abraham reported no potential conflicts of interest.


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