KONGRESSBERICHTEHow to rememberthe St.Gallen ConsensusConference 2011Bernhard C. P estalozzi,Universitätsspital, ZürichThis year, a total of 4200 participants from 95 countrieshave attended the 12 th St.Gallen International BreastCancer Conference on «Primary Therapy of Early BreastCancer (EBC) » which was held March 16-19, 2011. Thismeet<strong>in</strong>g has become a very important and visible benchmark<strong>for</strong> oncologists mak<strong>in</strong>g decisions with EBC patients.Hans-Joerg Senn and Aron Goldhirsch have succeededto attract the very best of breast cancer specialists fromall over the world. Both Gianni Bonadonna and BernardFisher, the ‘found<strong>in</strong>g fathers’ of adjuvant chemotherapy <strong>for</strong>EBC, were <strong>in</strong>volved <strong>in</strong> these conferences held s<strong>in</strong>ce 1978,organised by Hans-Joerg Senn. Appropriately, BernardFisher and Gianni Bonadonna were the fi rst recipients ofthe Breast Cancer Award, bestowed by the not-<strong>for</strong> profi tfoundation «St.Gallen Oncology Conferences» (SONK)s<strong>in</strong>ce the conference <strong>in</strong> 2003.It is fi tt<strong>in</strong>g to remember these two great men who havebeen crucial <strong>for</strong> the development of the St.Gallen Conferenceswe enjoy every two years. In his acceptance speech ofthe Breast Cancer Award <strong>in</strong> 2003 Bernie Fisher recited thepoem ‘Ithaca’ by Konstant<strong>in</strong>os Kavafi s. We were all surprisedto hear a scientist confess that he was «enamored»by Greek poetry. Similarly, Gianni Bonadonna has confessedon the St.Gallen podium that every time he camehere he visited the St.Gallen abbey and its magnifi centlibrary. The erudite Milanese professor was attracted bythe medieval scripts displayed there. When enter<strong>in</strong>g thelibrary the visitor is captivated by its exuberant baroqueatmosphere emanat<strong>in</strong>g from the richly decorated archi-tecture, the impressiveshowcases, bookshelvesand the ceil<strong>in</strong>g frescospa<strong>in</strong>ted <strong>in</strong> 1762 by JosefWannenmacher.These frescos show thefour oecumenical councilsof early Christianityat Nicaea (held <strong>in</strong>A.D. 325) (Figure 1),Constant<strong>in</strong>ople (381),Ephesos (431), andChalcedon (451). TheFirst Council <strong>in</strong> Nicaeawas a council of Christianbishops convenedby the Roman EmperorConstant<strong>in</strong>e I. TheCouncil was the fi rstef<strong>for</strong>t to atta<strong>in</strong> consensuswith<strong>in</strong> the Churchthrough an assemblyrepresent<strong>in</strong>g all ofChristendom. For thereligious lea<strong>der</strong>s of thattime these assembliesserved a similar purposeas the present daySt.Gallen conventionsdo <strong>for</strong> the lea<strong>der</strong>s <strong>in</strong>breast cancer oncology:IthacaByKonstant<strong>in</strong>osKavafis(1910)WhenyousetoutonyourjourneytoIthaca,praythattheroadislong,fullofadventure,fullofknowledge.…Praythattheroadislong.Thatthesummermorn<strong>in</strong>gsaremany,when,withsuchpleasure,withsuchjoyyouwillenterportsseen<strong>for</strong>thefirsttime;stopatPhoenicianmarkets,andpurchasef<strong>in</strong>emerchandise,motherofpearlandcoral,amberandebony,andsensualperfumesofallk<strong>in</strong>ds,asmanysensualperfumesasyoucan;visitmanyEgyptiancities,tolearnandlearnfromscholars.AlwayskeepIthaca<strong>in</strong>yourm<strong>in</strong>d.Toarrivethereisyourultimategoal.Butdonothurrythevoyageatall.Itisbettertoletitlast<strong>for</strong>manyyears;andtoanchorattheislandwhenyouareold,richwithallyouhavega<strong>in</strong>edontheway,notexpect<strong>in</strong>gthatIthacawillofferyouriches.Ithacahasgivenyouthebeautifulvoyage.Withoutheryouwouldhaveneversetoutontheroad.Shehasnoth<strong>in</strong>gmoretogiveyou.Andifyouf<strong>in</strong>dherpoor,Ithacahasnotdeceivedyou.Wiseasyouhavebecome,withsomuchexperience,youmustalreadyhaveun<strong>der</strong>stoodwhatIthacasmean.They brought together all the players, made them discussthe issues both privately and publicly, and had themissue a consensus statement which atta<strong>in</strong>ed consi<strong>der</strong>ableauthority. The questions discussed at these councils wereof fundamental importance to Christianity such as theconcept of the holy Tr<strong>in</strong>ity. One question discussed at Nicaeaby 300 bishops was whether Jesus Christ was God orwhether his was only «God-like». After a consensus wasreached that Jesus Christ was <strong>in</strong> fact God, the advocatesof the oppos<strong>in</strong>g view were persecuted and some of themwere killed. Fortunately, times have changed and m<strong>in</strong>or-Table 1. SurgerySurgery: Axilla cN0 % Yes % No % Absta<strong>in</strong>Is the use of IHC to look <strong>for</strong> low volume disease <strong>in</strong> the SN rout<strong>in</strong>ely <strong>in</strong>dicated 22.2 71.1 6.7Is completion of AD rout<strong>in</strong>ely <strong>in</strong>dicated <strong>for</strong> pts with ITCs un<strong>der</strong>go<strong>in</strong>g MX 6.4 91.5 2.1Is completion of AD rout<strong>in</strong>ely <strong>in</strong>dicated <strong>for</strong> pts with ITCs un<strong>der</strong>go<strong>in</strong>g BCT 0.0 93.3 6.7Pts with cN0 should proceed to completion AD if SN biopsy shows:ITCs <strong>in</strong> marg<strong>in</strong>al s<strong>in</strong>us and body of LN 0.0 97.7 2.3Micromets less than 0.2mm <strong>in</strong> a s<strong>in</strong>gle SN [Sx=BCT] 4.3 91.3 4.3Micromets of 0.2mm-2mm <strong>in</strong> a s<strong>in</strong>gle SN [after BCT] 18.6 76.7 4.7Can completion AD be omitted <strong>in</strong> a pt with 1-2 histologically pos. SNs after mastectomy 16.7 71.4 11.9AD axillary dissection, BCT breast conserv<strong>in</strong>g treatment, ITC isolated tumor cells, MX mastectomy, Sx surgery, SN sent<strong>in</strong>el node178 <strong>Schweiz</strong>er Krebsbullet<strong>in</strong> • Nr. 2/2011
KONGRESSBERICHTEFigure 1.Fresco by JosefWannenmacher(1762) atthe St.Gallenabbey,depict<strong>in</strong>g theEcumenicalCouncil of earlyChristianity atNicaea held <strong>in</strong>A.D. 325.ity views not only have become tolerated but they mayserve as prophecies to be confi rmed <strong>in</strong> a future cl<strong>in</strong>icaltrial. Although the metaphorical comparison with religiouscouncils may be somewhat stretched, the consensusstatements issued <strong>in</strong> St.Gallen have atta<strong>in</strong>ed a consi<strong>der</strong>abledegree of authority <strong>for</strong> the <strong>in</strong>ternational breast cancercommunity. There<strong>for</strong>e, the rea<strong>der</strong> is <strong>in</strong>vited to consi<strong>der</strong>not only the scientifi c and medical issues discussed, but topay particular attention to the word<strong>in</strong>g of the questions(Tables 1-8).As announced by the organiz<strong>in</strong>g committee the «Highlightsof the St.Gallen Meet<strong>in</strong>g 2011» will be publishedthis summer <strong>in</strong> Annals of Oncology. This publication willTable 2. Radiotherapy% % %RT <strong>for</strong> DCIS Yes No Absta<strong>in</strong>Should RT be consi<strong>der</strong>ed standard <strong>for</strong> entirely excised DCIS 67.6 24.3 8.1Can RT be avoided <strong>in</strong> el<strong>der</strong>ly (>70) [Sx = BCT] 58.3 33.3 8.3Can RT be avoided [<strong>in</strong> some] <strong>in</strong> low grade/low risk DCIS 61.7 31.9 6.4RT: Accelerated Whole Breast RTShould accelerated WBRT be consi<strong>der</strong>ed an acceptable option 91.5 4.3 4.3Should standard WBRT be preferred if extensive vascular <strong>in</strong>vasion present 34.8 32.6 32.6RT: Partial Breast Irradiation. In comb<strong>in</strong>ation with BCS, PBRT (<strong>in</strong>traoperative) is acceptableAs the def<strong>in</strong>itive irradiation, without any external beam RT 48.9 35.6 15.6With external beam RT if necessary 60.9 17.4 21.7Instead of external beam boost to tumor bed 61.8 11.8 26.5RT: Should Partial Breast Irradiation be applied <strong>in</strong> selected pts (<strong>in</strong>clud<strong>in</strong>g <strong>in</strong>traoperative)In el<strong>der</strong>ly (age >70) 86.7 6.7 6.7In lymphoma survivors after mantle field RT 37.2 25.6 37.2RT after Mastectomy (PMRT)Should PMRT be standard <strong>for</strong> pts with N+ ≥4 87.8 4.9 7.3Should PMRT be recommended to all pts with N+ 1-3 18.2 70.5 11.4Should PMRT be recommended to all pts with at least pT2 12.8 85.1 2.1Only if young [10% of cells or gene ratio >2) 68.1 23.4 8.5Subtypes and choice of therapyChoice of therapy depends on tumour subtype as def<strong>in</strong>ed by multi-gene array analysis 19.5 75.6 4.9For practical purposes tumor subtype can be ascerta<strong>in</strong>ed by non-genetic tests <strong>for</strong> ER, PgR, Her2 and Ki67 82.9 12.2 4.9Choice of cytotoxic therapy should be <strong>in</strong>fluenced by tumour subtype 74.4 18.6 7.0Multi-gene signatures[May] Oncotype DX be used to predict chemotherapy response <strong>in</strong> an endocr<strong>in</strong>e-responsive cohort? 84.4 11.1 4.4[May] Mammapr<strong>in</strong>t be used to predict chemotherapy responsiveness 29.8 63.8 6.4[Words <strong>in</strong> brackets refer to changes <strong>in</strong> word<strong>in</strong>g made dur<strong>in</strong>g the consensus conference, e.g. from «should» to «may»]<strong>Schweiz</strong>er Krebsbullet<strong>in</strong> • Nr. 2/2011 179
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