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Breast cancer is currently the most common malignant tumor in women in China, and 15%-20% of them are triple-negative breast cancer (TNBC). TNBC is also a malignant tumor with a poor prognosis because there are few treatments for it. At present, neoadjuvant therapy has become one of the standard treatment modes for breast cancer, which can bring clinical benefits to some breast cancer patients. In addition, with the emergence of many new therapeutic drugs in recent years, new treatment options and options for neoadjuvant therapy for breast cancer have also been provided.
The 2024 National Breast Cancer Conference and the Annual Meeting of the Chinese Society of Clinical Oncology for Breast Cancer (CSCO BC) was held in Beijing from April 12 to 13. At the conference, Professor Wang Shusen from the Cancer Center of Sun Yat-sen University made a detailed report on the key points of rescue and treatment of advanced TNBC involved in the "Guidelines".
Figure 1 Professor Wang Shusen is reporting on the key points of the update of the Guidelines
Key points of the update of the guideline: TNBC rescue treatment
Update point 1: The original rescue treatment recommendation form has been adjusted to two forms: rescue chemotherapy and rescue immunotherapy.
Rationale for update: Immunotherapy has become an important option for the TNBC population.
Update point 2: Recommendations for rescue immunotherapy based on KEYNOTE355 and TORCHLIGHT studies.
Rationale for Update: Research that changes clinical practice.
Fig.2 Key points and reasons for the update of TNBC rescue treatment
Current rescue regimens for advanced TNBC
01Rescue chemotherapy regimen
TNBC is a highly aggressive subtype, with ER, PR, and HER2 negative, and HER2 positive, both of which are prone to recurrence and metastasis. For TNBC patients, there are few treatment options, and chemotherapy, as one of the important means of treatment, has attracted much attention.
Among the rescue regimens recommended by the guidelines, the level I recommendations are all chemotherapy regimens. Even in the level II and III recommendations, most regimens are still chemotherapy-based. Among them, the recommendation of chemotherapy regimen includes both single-agent selection or combination regimen, and in clinical practice, it is necessary to reasonably select the appropriate chemotherapy regimen according to the clinicopathological characteristics and organ function status of patients.
Fig.3 Rescue chemotherapy for TNBC
02 Rescue immunization regimen
TNBC, as the most suitable breast cancer subtype for immunotherapy, demonstrated in the KEYNOTE-355 trial that pembrolizumab plus chemotherapy resulted in a significant increase in progression-free survival (PFS) in patients with metastatic TNBC compared with chemotherapy alone. In addition, there are also basic studies that show that PD-L1 monoclonal antibody can enhance the efficacy of chemotherapy. With the emergence of a series of evidence-based medical evidence and the improvement of drug accessibility, immunotherapy has become an important option for PD-L1-positive advanced TNBC.
In addition, in June 2022, gosatuzumab, the world's first Trop-2-targeting ADC drug, was approved by the National Medical Products Administration (NMPA) of China for adult patients with unresectable locally advanced or metastatic TNBC who have received at least two prior systemic therapies, at least one of which is for metastatic disease, bringing more treatment options to patients with advanced TNBC in China.
Fig.4 TNBC rescue immunotherapy
03 Rescue targeted program
The success of PARPi targeting BRCA mutations has rewritten domestic and international guidelines for advanced TNBC, and the treatment of targeted NTRK fusions has also been written into NCCN guidelines. However, targeted therapies are still only suitable for a niche population.
Fig.5 Targeted therapy is currently a niche option for advanced TNBC
Summary
01
Chemotherapy remains the mainstay
The Level I recommendations in the Guidelines are all chemotherapy or combination therapy containing chemotherapy. It is expected that with the increase of evidence-based medical evidence, more chemotherapy drugs or new combination regimens containing chemotherapy will enter or rewrite the guidelines for advanced TNBC in the future.
02
Immunotherapy has become an important option
TNBC is the most suitable subtype of breast cancer for immunotherapy. With the emergence of a series of evidence-based medical evidence and the improvement of drug accessibility, immunotherapy has become an important option for PD-L1-positive advanced TNBC.
03
Targeted therapy is currently only available to a small number of people
Currently, targeted therapies are still only suitable for a niche population. In addition, there are a large number of clinical trials of TNBC-targeted therapies targeting specific receptors or based on immunohistochemical staining results, and it is expected that more highly effective targeted therapies will be written into guidelines in the near future.
04
ADC drugs have a bright future
With the approval of gosatuzumab for the indication of late-stage TNBC in mainland China, the clinical options for late-stage TNBC in mainland China have been further enriched. At present, there are other ADC drugs for advanced TNBC that are gradually being studied, and clinical studies of ADC in combination with immunotherapy have shown encouraging preliminary efficacy.
Expert Profile
Professor Wang Shusen
- Sun Yat-sen University Cancer Hospital, Chief Expert Professor, Chief Physician and Doctoral Supervisor of Breast Cancer
- Vice Chairman of the Breast Cancer Committee of the Chinese Association of Research Hospitals
- Vice Chairman of the Tumor Endocrinology Committee of the Chinese Anti-Cancer Association
- Vice Chairman of the Breast Cancer Expert Committee of the Chinese Society of Clinical Oncology (CSCO).
- He is a member of the Standing Committee of the Breast Cancer Committee of the Chinese Anti-Cancer Association
- Chairman of the Chemotherapy Professional Committee of Guangdong Anti-Cancer Association
- Chairman of the Expert Committee on Quality Control of Breast Cancer Diagnosis and Treatment of Guangdong Cancer Center
- Chairman of the Breast Cancer Professional Committee of Guangdong Thoracic Tumor Prevention and Treatment Research Association
- Vice Chairman of the Breast Cancer Professional Committee of Guangdong Anti-Cancer Association
- Vice Chairman of the Breast Cancer Committee of Guangdong Southern Cancer Clinical Research Association
- Vice Chairman of the Breast Specialty Working Committee of Guangdong Medical Doctor Association
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Audit Expert: Professor Wang Shusen
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