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Quality indicators in breast cancer care: An update from the EUSOMA working group

Published:September 27, 2017DOI:https://doi.org/10.1016/j.ejca.2017.08.017

      Abstract

      In 2010, EUSOMA published a position paper, describing a set of benchmark quality indicators (QIs) that could be adopted by breast centres to allow standardised auditing and quality assurance and to establish an agreed minimum standard of care. Towards the end of 2014, EUSOMA decided to update the paper on QIs to consider and incorporate new scientific knowledge in the field. Several new QIs have been included to address the need for improved follow-up care of patients following primary treatments. With regard to the management of elderly patients, considering the complexity, the expert group decided that, for some specific quality indicators, if centres fail to meet the minimum standard, older patients will be excluded from analysis, provided that reasons for non-adherence to the QI are specified in the clinical chart and are identified at the review of the clinical records. In this way, high standards are promoted, but centres are able to identify and account for the effect of non-standard treatment in the elderly. In the paper, there is no QI for outcome measurements, such as relapse rate or overall survival. However, it is hoped that this will be developed in time as the databases mature and user experience increases. All breast centres are required to record outcome data as accurately and comprehensively as possible to allow this to occur. In the paper, different initiatives undertaken at international and national level to audit quality of care through a set of QIs have been mentioned.

      Keywords

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        Patterns and trends in immediate postmastectomy reconstruction in California: complications and unscheduled readmissions.
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        National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012.
        Am J Surg. 2015 Sep; 210: 512-516

      10: Postoperative RT

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        • Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO)
        DEGRO practical guidelines: radiotherapy of breast cancer I: radiotherapy following breast conserving therapy for invasive breast cancer.
        Strahlenther Onkol. 2013 Oct; 189: 825-833
        • Kunkler I.H.
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        • Jack W.J.
        • Cameron D.A.
        • Dixon J.M.
        • PRIME II investigators
        Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial.
        Lancet Oncol. 2015 Mar; 16 (Erratum in: Lancet Oncol. 2015 Mar;16(3):e105): 266-273https://doi.org/10.1016/S1470-2045(14)71221-5
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        Eur J Cancer. 2013 Jul; 49: 2294-2302
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        Can older women with early breast cancer avoid radiation?.
        Lancet Oncol. 2015 Mar; 16: 235-237
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        • Pakisch B.
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        Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer.
        Int J Radiat Oncol Biol Phys. 2007 Jun 1; 68: 334-340
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        Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer.
        N Engl J Med. 2004 Sep 2; 351: 963-970
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        Lancet. 2005 Dec 17; 366: 2087-2106
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        Lancet. 2014 Jun 21; 383: 2127-2135
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        Internal mammary and medial supraclavicular irradiation in breast cancer.
        N Engl J Med. 2015; 373: 317-327
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        Regional nodal irradiation in early-stage breast cancer.
        N Engl J Med. 2015; 373: 307-316
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        DBCG-IMN: a population-based cohort study on the effect of internal mammary node irradiation in early node-positive breast cancer.
        J Clin Oncol. 2016 Feb 1; 34: 314-320
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        Int J Radiat Oncol Biol Phys. 2013; 86: 867-872
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        Management of the regional lymph nodes following breast-conservation therapy for early-stage breast cancer: an evolving paradigm.
        Int J Radiat Oncol Biol Phys. 2014; 90: 772-777
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        Does the intent to irradiate the internal mammary nodes impact survival in women with breast cancer? A population-based analysis in British Columbia.
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        Radiotherapy for invasive breast cancer: guidelines for clinical practice.
        Crit Rev Oncol Hemat. 2011; 79 (e 148–160)

      11: Avoidance of overtreatment

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        Ann Surg. 2010 Apr; 251: 595-600
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        A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer.
        N Engl J Med. 2003 Aug 7; 349: 546-553
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        Sentinel node biopsy compared with complete axillary dissection for staging early breast cancer with clinically negative lymph nodes: results of randomized trial.
        Ann Oncol. 2009 Jun; 20: 1001-1007
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        • et al.
        Management of elderly patients with breast cancer: up-dated recommendations of the International Society of Geriatric Oncology. (SIOG) and European Society of Breast Cancer Specialists (EUSOMA).
        Lancet Oncol. 2012; 13: 148-160
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        • Fallowfield L.
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        • Goyal A.
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        Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC trial.
        J Natl Cancer Inst. 2006 May 3; 98 (Erratum in: J Natl Cancer Inst. 2006 Jun 21;98(12):876): 599-609
        • Veronesi U.
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        A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer.
        N Engl J Med. 2003; 349: 546-553
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        Sentinel-lymph node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial.
        Lancet Oncol. 2010; 11: 927-933
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        J Natl Cancer Inst. 2006 May 3; 98: 599-609
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        J Clin Oncol. 2010; 102: 111-118
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        Optimal number of radioactive sentinel lymph nodes to remove for accurate axillary staging of breast cancer.
        Surgery. 2008 Oct; 144 (discussion 531–532): 525-531
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        • Keto J.L.
        • Tran H.
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        First three sentinel lymph nodes accurately stage the axilla in breast cancer.
        Am Surg. 2009 Mar; 75: 253-256
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        • McCready D.R.
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        Quality indicators for sentinel lymph node biopsy: is there room for improvement?.
        Can J Surg. 2013 Apr; 56: 82-88https://doi.org/10.1503/cjs.033011
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        • Park S.
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        How many sentinel lymph nodes are enough for accurate axillary staging in t1-2 breast cancer?.
        J Breast Cancer. 2011 Dec; 14: 296-300
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        Cancer. 2008 Jul 1; 113: 30-37https://doi.org/10.1002/cncr.23514
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        J Am Coll Surg. 2001 Jun; 192: 692-697
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        Number of lymph nodes removed in sentinel lymph node-negative breast cancer patients is significantly related to patient age and tumor size: a new source of bias in morbidity assessment?.
        Cancer. 2015; 116 (article published online)
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        Long-term morbidity following axillary dissection in breast cancer patients – clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors.
        Breast Cancer Res Treat. 2000 Dec; 64: 275-286
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        J Natl Cancer Inst. 2006 May 3; 98: 599-609
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        • et al.
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        J Clin Oncol. 2010; 102: 111-118
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        • et al.
        • for the National Surgical Adjuvant Breast and Bowel Project (NSABP)
        Technical outcomes of sentinel-node-resection and conventional axillary-lymph-node dissection in patients with clinically node-negative breast cancer: results from the NSABP B-32 randomised phase III trial.
        Lancet Oncol. 2007; 8: 881-888
        • Krag D.N.
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        • Julian T.B.
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        • Harlow S.P.
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        • et al.
        Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial.
        Lancet Oncol. 2010 Oct; 11: 927-933https://doi.org/10.1016/S1470-2045(10)70207-2
        • Veronesi U.
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        • et al.
        Twenty-year follow-up of a randomized study comparing breast conserving surgery with radical mastectomy for early breast cancer.
        N Engl Med. 2002; 347: 1227-1232
        • Fisher B.
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        • et al.
        Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy and lumpectomy plus irradiation for the treatment of invasive breast cancer.
        N Engl J Med. 2002; 347: 1233-1241
        • Jatoi I.
        • Proschan M.A.
        Randomized trials of breast conserving therapy versus mastectomy for primary breast cancer: a pooled analysis of updated results.
        Am J Clin Oncol. 2005; 28: 289-294
        • EBCTCG
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        Effect of radiotherapy alter breast conserving surgery on 10-year recurrence and 15-year breast cancer death. Meta-analysis of individual patient data for 10.801 women in 17 randomised trials.
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        • Clarke M.
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        Lancet. 2005; 366: 2082
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        • Schnitt S.J.
        • Giuliano A.E.
        • et al.
        Society of Surgical Oncology –American Society for Radiation Oncology Consensus Guideline on margins in breast-conserving surgery with whole breast irradiation in stages I or II invasive breast cancer.
        J Clin Oncol. 2013; https://doi.org/10.1200/JCO.2013.53.3935
        • Goodwin A.
        • Parker S.
        • Ghersi D.
        • Wilcken N.
        Post-operative radiotherapy for ductal carcinoma in situ of the breast–a systematic review of the randomised trials.
        Breast. 2009 Jun; 18: 143-149
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        • et al.
        Effect of radiotherapy after breast-conserving surgery for ductal carcinoma in situ: 20 years follow-up in the randomized SweDCIS trial.
        J Clin Oncol. 2014 Nov 10; 32: 3613-3618
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        • de Lafontan B.
        • Giard S.
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        Br J Cancer. 2009; 100: 1048-1054
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        • Gray R.
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        Local excision alone without irradiation for ductal carcinoma in situ of the breast: a trial of the Eastern Cooperative Oncology Group.
        J Clin Oncol. 2009 Nov 10; 27: 5319-5324
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        • Gelman R.
        • Lester S.C.
        • Schnitt S.J.
        • et al.
        Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS).
        Breast Cancer Res Treat. 2014 Jan; 143: 343-350
        • Narod S.A.
        • Iqbal
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        • Sun P.
        Breast cancer mortality after a diagnosis of ductal carcinoma in situ.
        JAMA Oncol. 2015; 1: 888-896
        • Dunne C.
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        • Morrow M.
        • Kell M.R.
        Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ.
        J Clin Oncol. 2009; 27: 1615-1620
        • Ponti A.
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        • von Euler-Chelpin M.
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        • et al.
        • ICSN DCIS Working group
        International variation in management of screen-detected ductal carcinoma in situ of the breast.
        Eur J Cancer. 2014 Oct; 50: 2695-2704
        • Schwarz G.F.
        The consensus conference on the treatment of the in situ ductal carcinoma of the breast 22–25 April 1999.
        Cancer. 2000; 88: 945-954
        • Cody 3rd, H.S.
        Preoperative sentinel lymph node biopsy: adding nuance to the management of locally recurrent breast cancer.
        Ann Surg Oncol. 2006 Jul 26;
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        Variations in the management of the axilla in screen-detected ductal carcinoma in situ: evidence from the UK NHS breast screening programme audit of screen detected DCIS.
        Eur J Surg Oncol. 2015 Jan; 41: 86-93
        • Julian T.B.
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        Is sentinel node biopsy necessary in conservatively treated DCIS?.
        Ann Surg Oncol. 2007 Aug; 14: 2202-2208
        • Giuliano A.E.
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        Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.
        JAMA. 2011 Feb 9; 9: 569-575

      12: Appropriate endocrine therapy

        • Early Breast Cancer Trialists' Collaborative Group (EBCTCG)
        Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials.
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        • von Minckwitz G.
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        14th St. Gallen International Breast Cancer Conference 2015: evidence, controversies, consensus – primary therapy of early breast cancer: opinions expressed by German Experts.
        Breast Care (Basel). 2015 Jul; 10: 211-219
        • Dowsett M.
        • Forbes J.F.
        • Bradley R.
        • Ingle J.
        • Aihara T.
        • Bliss J.
        • et al.
        • Early Breast Cancer Trialists' Collaborative Group (EBCTCG)
        Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials.
        Lancet. 2015 Oct 3; : 386
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        • Panel Members
        Tailoring therapies—improving the management of early breast cancer: St Gallen International Expert Consensus on the primary therapy of early breast cancer.
        Ann Oncol. 2015; 26: 1533-1546
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        • Regan Meredith M.
        • Fleming Gini F.
        • et al.
        Adjuvant ovarian suppression in premenopausal breast cancer.
        New Engl J Med. 2014;
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        • et al.
        Adjuvant exemestane with ovarian suppression in premenopausal breast cancer.
        N Engl J Med. 2014; 371: 107-118
        • Biganzoli L.
        • Wildiers H.
        • Oakman C.
        • Marotti L.
        • Loibl S.
        • Kunkler I.
        • et al.
        Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA).
        Lancet Oncol. 2012 Apr; 13 (Epub 2012 Mar 30): e148-e160

      13: Appropriate chemotherapy and HER2-targeted therapy

      1. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Early Breast Cancer Trialists' Collaborative Group (EBCTCG).
        Lancet. 2005; 365: 1687-1717
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        • et al.
        Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up national comprehensive cancer network guidelines version 3.2015. Invasive breast cancer.
        Ann Oncol. 2015; 26: v8-v30
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        • et al.
        2-year follow-up of trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer: a randomised controlled trial.
        Lancet. 2007; 369: 29-36
        • Romond E.H.
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        • et al.
        Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer.
        N Engl J Med. 2005; 353: 1673-1684
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        Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer.
        N Engl J Med. 2006; 354: 809-820
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        • Robert N.
        • et al.
        Phase III trial comparing AC-T with AC-TH and with TCH in the adjuvant treatment of HER2 positive early breast cancer patients: second interim efficacy analysis.
        SABCS. 2006; (National Comprehensive Cancer Network Guidelines version 3.2015. Invasive breast cancer)
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        Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
        Ann Oncol. 2015; 26: v8-v30
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        • Ibrahim N.K.
        • Francis D.
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        Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in human epidermal growth factor receptor 2-positive operable breast cancer.
        J Clin Oncol. 2005; 23: 3676-3685
        • Buzdar A.U.
        • Valero V.
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        Neoadjuvant therapy with paclitaxel followed by 5-fluorouracil, epirubicin, and cyclophosphamide chemotherapy and concurrent trastuzumab in human epidermal growth factor receptor 2-positive operable breast cancer: an update of the initial randomized study population and data of additional patients treated with the same regimen.
        Clin Cancer Res. 2007; 13: 228-233
        • Gianni L.
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        Neoadjuvant chemotherapy with trastuzumab followed by adjuvant trastuzumab versus neoadjuvant chemotherapy alone, in patients with HER2-positive locally advanced breast cancer (the NOAH trial) a randomized controlled superiority trial with a parallel HER2-negative cohort.
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        Neoadjuvant and adjuvant trastuzumab in patients with HER2-positive locally advanced breast cancer (NOAH): follow-up of a randomised controlled superiority trial with a parallel HER2-negative cohort.
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        Neoadjuvant treatment with trastuzumab in HER2-positive breast cancer: results from the Gepar Quattro study.
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        Pathologic complete response after neoadjuvant chemotherapy plus trastuzumab predicts favorable survival in human epidermal growth factor receptor 2-overexpressing breast cancer: results from the TECHNO trial of the AGO and GBG study groups.
        J Clin Oncol. 2011; 29: 3351-3357
        • Buzdar A.U.
        • Suman V.J.
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        Fluorouracil, epirubicin, and cyclophosphamide (FEC-75) followed by paclitaxel plus trastuzumab versus paclitaxel plus trastuzumab followed by FEC-75 plus trastuzumab as neoadjuvant treatment for patients with HER2-positive breast cancer (Z1041): a randomised, controlled, phase 3 trial.
        Lancet Oncol. 2013 Dec; 14: 1317-1325
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        Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis.
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        • Merajver S.D.
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        • et al.
        International expert panel on inflammatory breast cancer: consensus statement for standardized diagnosis and treatment.
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        • Cristofanilli M.
        • Gonzalez-Angulo A.M.
        • Buzdar A.U.
        • Kau S.W.
        • Frye D.K.
        • Hortobagyi G.N.
        Paclitaxel improves the prognosis in estrogen receptor negative inflammatory breast cancer: the M. D. Anderson Cancer Center experience.
        Clin Breast Cancer. 2004 Feb; 4: 415-419
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        Neoadjuvant chemotherapy with trastuzumab followed by adjuvant trastuzumab versus neoadjuvant chemotherapy alone, in patients with HER2-positive locally advanced breast cancer (the NOAH trial): a randomised controlled superiority trial with a parallel HER2-negative cohort.
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        • Herold C.I.
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        Cancer Invest. 2008; 26: 1052-1059

      14: Appropriate staging procedure

        • Groheux D.
        • Hindie E.
        Breast cancer staging: to which women 18FDG-PET/CT should be offered?.
        J Nucl Med. 2015 Jun 4; (pii: jnumed.115.160945)
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      15: Perform appropriate follow up

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      17: The availability of data manager

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      Conclusion

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