LBCA SAB Member, Dr. Shani Paluch-Shimon, is the Breast Oncology Program Director at Hadassah University Hospital in Jerusalem and a medical oncologist with a Masters in Epidemiology from the London School of Hygiene & Tropical Medicine. She explains in layman terms how to make sense of the recently published 6th and 7th International Consensus Guidelines for the Management of Advanced Breast Cancer.  The ABC guidelines are based on the most up-to-date evidence that can be used to guide treatment decisions in different healthcare settings globally. They are updated at each biennial Advanced Breast Cancer International Consensus Conference hosted by the ABC Global Alliance.

Can you please tell us what your role is with regard to these international guidelines? How did you get involved with this?

I have been involved in clinical guideline work for many years. The background to this is my understanding that not all women receive their care in tertiary academic centers – many women receive their care in community settings. Additionally, in countries or areas with fewer resources, a woman may receive care by a general oncologist who does not specialize specifically or exclusively in breast cancer.

Why are clinical guidelines important and who uses them? 

International guidelines help ensure patients receive the highest standard of care by making the important clinical trial data accessible and organized, defining categorically best standard of care. Studies have shown that women who receive guideline-based therapy do better! Also, with a rapidly changing treatment landscape, guidelines help sort, interpret and digest the data but also help identify areas of need for ongoing research.

There are specific methodologies for creating guidelines with predefined levels of evidence and each recommendation in a guideline will be followed by a code or score identifying the level of evidence and a grade of recommendation. For example – the highest level of evidence would be from a well-designed randomized control study and the lowest level of evidence may be based on case series or expert opinion, if no randomized control trial data is available. The grade of recommendation by the panel of authors will depend on the level, quality and quantity of the evidence to support the recommendation and takes into account the risks and benefits of that recommendation.

I saw the opportunity to be involved in clinical practice guidelines as an opportunity to have a broader and meaningful impact on the care of women globally. Over the years, I have authored the international guidelines on care for young women with breast cancer and on prevention and screening of cancer in individuals with hereditary breast and ovarian cancer syndrome. I have been involved in guidelines for both early and advanced breast cancer and I served for three terms as the subject editor for breast cancer for the ESMO (European Society of Medical Oncology) clinical practice guidelines committee. There are many available guidelines nationally and internationally – there are many reasons for this, but include that in some countries reimbursement of new medications depend on whether national or international guidelines exist and whether they support a certain treatment approach.

Are there any changes / new information included in these guidelines regarding the management of advanced ILC? If so, what are they? 
In terms of invasive lobular breast carcinoma – the guidelines do distinguish between the different subtypes and highlight the need for different imaging for lobular carcinoma, that the biology of lobular carcinomas is different and that this necessitates a tailored treatment approach.

What needs to be accomplished in the field for there to be new or additional changes to guidelines like these related to the management of advanced ILC? 
The ABC6-7 guidelines that were published this year are the most recent international guidelines for patients with advanced breast cancer and the activity was spearheaded by Dr Fatima Cardoso from Portugal on behalf of the ABC Global Alliance. Dr Cardoso pioneered incorporating patient advocates in conference programs and in consensus guidelines panels. Specifically, the ABC Global Alliance conferences give a strong voice to women living with advanced breast cancer and patient advocates are integral in planning and running the program. The conferences take place every two years – ABC8 will take place in Lisbon, Portugal in 2025 – and each time focuses on new, unique and evolving issues in the management of advanced breast cancer. For example in previous chapters/editions the topic of invasive lobular carcinoma has been addressed and highlighted and if there were to be new evidence on treatment paradigms for lobular carcinoma, that would be incorporated in the guidelines.

Is there anything else you would like to add for those interested in ILC and clinical guidelines?
I anticipate that in the coming years we will have more data on the biology of ILC, on better imaging and more data on tailored treatment – as soon as there is data that is practice changing – that would be incorporated in the guidelines.

To read the complete 6th and 7th International Consensus Guidelines for the Management of Advanced Breast Cancer click here.