Breast Cancer (ABC) comprises both locally advanced breast cancer (LABC) and metastatic breast cancer (MBC) [1]. Although treatable, MBC remains virtually an incurable disease with a median overall survival (OS) of $3 years and a 5-year survival of only $25% [2, 3]. The MBC Decade Report [2] shows that progress has been slow in terms of improved outcomes, quality of life (QoL), awareness and information regarding ABC. More recently, some studies seem to indicate an improvement in OS, mostly due to advances in human epidermal growth factor receptor 2 (HER2)-positive ABC [4][5][6]. The better survival is seen in an environment with access to the best available care and particularly in de novo ABC, while recurrent ABC seems to become harder to manage [7,8].The last decade has seen an improvement in the levels of evidence (LoEs) used for many of the ABC recommendations, however, still far from the LoEs existing for the majority of early

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Background Distant metastatic breast cancer (MBC), including metastases found at diagnosis (de novo) and those occurring later (recurrence), represents the most severe form of the disease, when resource utilization is most intensive. Yet, the number of women living with MBC in the US is unknown. The objective of this paper is to use population-based data to estimate the prevalence of MBC. Methods We used a back-calculation method to estimate MBC prevalence from US BC mortality and survival from the Surveillance, Epidemiology and End Results (SEER) registries. Based on the illness-death process, this method assumes that each observed BC death is the result of MBC, either de novo or a recurrence with metastatic disease. Results We estimate that by January 1, 2017 there will be 154,794 women living with MBC in the United States, 3 in 4 initially diagnosed with stage I–III BC who later progressed to MBC. Median survival and 5-year relative survival for de novo MBC increased over the years, especially in younger women. We estimate a 2-fold increase in 5-year relative survival from 18% to 36%, for women diagnosed with de novo MBC at age 15–49 between 1992–1994 and 2005–2012, respectively. Conclusion This study demonstrates an increasing number of women in the US living with MBC, likely the result of improvements in treatment and aging of the US population. Impact The increasing burden of MBC highlights the importance of documenting recurrence in order to foster more research into the specific needs of this understudied population.

The ABC community strongly calls for clinical trials addressing important unanswered clinical questions in this setting, and not just for regulatory purposes. Clinical trials should continue to be performed, even after approval of a new treatment, providing real world performance of the therapy. Expert opinionVoters: 43 Yes: 100%Every advanced breast cancer patient must have access to optimal cancer treatment and supportive care according to the highest standards of patient centered care, as defined by:Open communication between patients and their cancer care teams as a primary goal.Educating patients about treatment options and supportive care, through development and dissemination of evidencebased information in a clear, culturally appropriate form. Encouraging patients to be proactive in their care and to share decision-making with their health care providers.Empowering patients to develop the capability of improving their own quality of life within their cancer experience. Always taking into account patient preferences, values and needs as essential to optimal cancer care. Expert opinion Voters: 44 Yes: 100% We strongly recommend the use of objective scales, such as the ESMO Magnitude of Clinical Benefit Scale or the ASCO Value Framework, to evaluate the real magnitude of benefit provided by a new treatment and help prioritize funding, particularly in countries with limited resources. Expert opinion Voters: 40 Yes: 87.5% (35) Abstain: 5% (2) The use of telemedicine oncology to help management of patients with ABC living in remote places, is an important option to consider when geographic distances are a problem and provided that issues of connectivity are solved. Expert opinion Voters: 42 Yes: 92.8% (39) Abstain: 4.7% (2) Strong consideration should be given to the use of validated PROMs (patient-reported outcome measures) for patients to record the symptoms of disease and side effects of treatment experienced as a regular part of clinical care. These PROMs should be simple, and user-friendly to facilitate their use in clinical practice, and thought needs to be given to the easiest collection platform, e.g. tablets or smartphones. Systematic monitoring would facilitate communication between patients and their treatment teams by better characterizing the toxicities of all anticancer therapies. This would permit early intervention of supportive care services enhancing quality of life 1 C Voters: 39 Yes: 87.1% (34) Abstain: 5.1% (2)As survival is improving in many patients with ABC, consideration of survivorship issues should be part of the routine care of these patients. Health professionals should therefore be ready to change and adapt treatment strategies to disease status, treatment adverse effects and quality of life, patients' priorities and life plans. Attention to chronic needs for home and family care, job and social requirements, should be incorporated in the treatment planning and periodically updated. Expert opinion Voters: 40 Yes: 95% (38) Abstain: 5% (2) ABC patients who desire to work or need to w...

Purpose: registHER is a prospective, observational study of 1,023 newly diagnosed HER2-positive metastatic breast cancer (MBC) patients.Experimental Design: Baseline characteristics of patients with and without central nervous system (CNS) metastases were compared; incidence, time to development, treatment, and survival after CNS metastases were assessed. Associations between treatment after CNS metastases and survival were evaluated.Results: Of the 1,012 patients who had confirmed HER2-positive tumors, 377 (37.3%) had CNS metastases. Compared with patients with no CNS metastases, those with CNS metastases were younger and more likely to have hormone receptor-negative disease and higher disease burden. Median time to CNS progression among patients without CNS disease at initial MBC diagnosis (n ¼ 302) was 13.3 months. Treatment with trastuzumab, chemotherapy, or surgery after CNS diagnosis was each associated with a statistically significant improvement in median overall survival (OS) following diagnosis of CNS disease (unadjusted analysis: trastuzumab vs. no trastuzumab, 17.5 vs. 3.8 months; chemotherapy vs. no chemotherapy, 16.4 vs. 3.7 months; and surgery vs. no surgery, 20.3 vs. 11.3 months). Although treatment with radiotherapy seemed to prolong median OS (13.9 vs. 8.4 months), the difference was not significant (P ¼ 0.134). Results of multivariable proportional hazards analyses confirmed the independent significant effects of trastuzumab and chemotherapy (HR ¼ 0.33, P < 0.001; HR ¼ 0.64, P ¼ 0.002, respectively). The effects of surgery and radiotherapy did not reach statistical significance (P ¼ 0.062 and P ¼ 0.898, respectively).Conclusions: For patients with HER2-positive MBC evaluated in registHER, the use of trastuzumab, chemotherapy, and surgery following CNS metastases were each associated with longer survival.