SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor
description
Transcript of SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor
![Page 1: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/1.jpg)
SABCS 2011
Metastatic Breast Cancer
Shiuh-Wen Luoh MD PhDClinical Associate Professor
Comprehensive Breast Cancer ClinicHematology and Medical Oncology
Knight Cancer Institute, OHSU
Portland VA Medical Center
![Page 2: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/2.jpg)
BOLERO-2
SWOG-0226
![Page 3: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/3.jpg)
![Page 4: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/4.jpg)
![Page 5: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/5.jpg)
![Page 6: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/6.jpg)
![Page 7: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/7.jpg)
![Page 8: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/8.jpg)
![Page 9: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/9.jpg)
![Page 10: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/10.jpg)
![Page 11: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/11.jpg)
![Page 12: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/12.jpg)
![Page 13: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/13.jpg)
![Page 14: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/14.jpg)
![Page 15: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/15.jpg)
![Page 16: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/16.jpg)
![Page 17: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/17.jpg)
![Page 18: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/18.jpg)
![Page 19: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/19.jpg)
![Page 20: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/20.jpg)
![Page 21: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/21.jpg)
![Page 22: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/22.jpg)
A phase III randomized trial of anastrozole versus anastrozole and fulvestrant as first-line therapy for
postmenopausal women with metastatic breast cancer: SWOG
S0226Mehta RS, Barlow WE, Albain KS,
Vandenberg TA, Dakhil SR, Tirumali NR, Lew DL, Hayes DF, Gralow JR,
Livingston RB, and Hortobagyi GN
![Page 23: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/23.jpg)
BackgroundAnastrozole lowers estrogen levels and fulvestrant
down-regulates the estrogen receptorThe combination of anastrozole and fulvestrant may
be additive in postmenopausal breast cancerFulvestrant has a high efficacy in low-estrogen in
vivo model (Osborne JNCI 1995)The combination of fulvestrant and anastrozole
down-regulates several resistance proteins in in vivo model (Macedo et al. Cancer research 2008)
![Page 24: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/24.jpg)
S0226: Main Eligibility Criteria• Postmenopausal women with metastatic breast cancer
(measurable or non-measurable)
• ER-positive or PgR-positive by local institutional standards
• No prior chemotherapy, hormonal therapy, or immunotherapy for metastatic disease
• Prior adjuvant tamoxifen allowed (stratification factor)
• Prior adjuvant AI allowed if completed 12 months earlier
• Neoadjuvant or adjuvant chemotherapy completed more than 12 months prior
• Patients were not allowed chemotherapy or other hormone therapy while on treatment
• Must have given informed consent
![Page 25: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/25.jpg)
![Page 26: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/26.jpg)
RANDOMIZE
Arm 1Anastrozole only: 1 mg PO daily
Treat until progression; crossover to fulvestrant strongly encouraged after progression
Arm 2Anastrozole: 1 mg PO dailyFirst cycle of 28 days: Fulvestrant 500mg IM ( 2 x 5 mL) Day 1 Fulvestrant 250mg IM ( 1 x 5 mL) Day 14 Fulvestrant 250mg IM ( 1 x 5 mL) Day 28Subsequent cycles of 28 days: Fulvestrant 250mg IM ( 1 x 5 mL) Day 28
Treat until progression
S0226: Schema
![Page 27: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/27.jpg)
S0226: Statistical Design• Accrual goal: 690 eligible patients equally allocated and
stratified by use of adjuvant tamoxifen• Primary endpoint: Progression-free survival (PFS)
– 90% power to detect an increase in median PFS from 10 months (monotherapy) to 13 months (combination) with 2-sided α = 0.05 overall
• Planned analyses of the primary endpoint– Two interim analyses at 50% and 75% of the events– Final analysis at 2-sided α = 0.04• Subset analyses were not planned and are not
adjusted for multiplicity• Overall survival is a secondary endpoint
![Page 28: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/28.jpg)
Primary Comparisons• Intent-to-treat analysis of eligible patients• Analysis stratified by prior adjuvant tamoxifen• Results to be presented today:
– Population characteristics• 707 patients randomized in the period
June 2004 to June 2009• 694 analyzed excluding 12 ineligible patients
and one who withdrew consent– Progression-free survival– Overall survival– Toxicity
![Page 29: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/29.jpg)
Patient CharacteristicsCharacteristic Anastrozole Anastrozole +
FulvestrantTotal
Randomized 352 355 707Ineligible or withdrew consent 7 (2.0%) 6 (1.7%) 13 (1.8%)
Analyzed 345 349 694Age median (range) 65 (36-91) 65 (27-92) 65 (27-92)Prior adjuvant tamoxifen 139 (40.3%) 141 (40.4%) 280 (40.3%)Prior adjuvant chemo 103 (29.9%) 129 (37.0%) 232 (33.4%)Disease characteristics Measurable 54.5% 53.9% 54.2% Bone only 22.0% 21.5% 21.8% De novo metastatic disease 41.8% 36.0% 38.9%
> 10 years since previous dx 26.1% 30.7% 28.4%
HER2-positive 8.5% 10.4% 9.5%
Use of adjuvant AI is being determined retrospectively, but only 12 users of adjuvant AI’s have been identified.
![Page 30: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/30.jpg)
Crossover• Patients in the anastrozole arm were strongly
encouraged to crossover to fulvestrant after progression
• After Feb 15, 2011 patients on either arm could crossover to 500 mg fulvestrant dosing after progression
• 143 of 345 patients (41%) on anastrozole did crossover to fulvestrant after progression (including 5 who took the 500 mg dosing)
• 9 of 349 patients on the combination took500 mg dosing after progression
![Page 31: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/31.jpg)
HR = 0.80 (95% CI 0.68 - 0.94)
Median PFS
Combination 15.0 mos (95% CI 13.2-18.4)Anastrozole 13.5 mos (95% CI 12.1-15.1)
0.00
0.25
0.50
0.75
1.00
Prog
ress
ion-
free
surv
ival
345 193 92 39 11 3 0AN + FV349 199 114 53 21 8 2AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (268 events)Anastrozole (297 events)Stratified log-rank p = 0.0070
All eligible patients (n=694)Progress ion-Free Surv ival in S0226
![Page 32: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/32.jpg)
HR = 0.89 (95% CI 0.69 - 1.15)
Anastrozole 14.1 mos (95% CI 12.0-16.8)Median PFS
Combination 13.5 mos (95% CI 11.0-19.3)
0.00
0.25
0.50
0.75
1.00
Prog
ress
ion-
free
surv
ival
139 80 32 17 3 1 0AN + FV141 74 43 17 5 2 1AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (114 events)Anastrozole (119 events)
Log-rank p = 0.37
Prior adjuvant tamoxifen (n=280)Progress ion-Free Surv ival in S0226
![Page 33: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/33.jpg)
HR = 0.74 (95% CI 0.59-0.92)
Median PFSAnastrozole 12.6 mos (95% CI 11.2-15.6)Combination 17.0 mos (95% CI 13.8-19.9)
0.00
0.25
0.50
0.75
1.00
Prog
ress
ion-
free
surv
ival
206 113 60 22 8 2 0AN + FV208 125 71 36 16 6 1AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (154 events)Anastrozole (178 events)
Log-rank p = 0.0055
No prior adjuvant tamoxifen (n=414)Progress ion-Free Surv ival in S0226
![Page 34: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/34.jpg)
Median OSAnastrozole 41.3 mos (95% CI 37.2-45.0)Combination 47.7 mos (95% CI 43.4-55.7)
HR = 0.81 (95% CI 0.65 - 1.00)
0.00
0.25
0.50
0.75
1.00
Over
all S
urvi
val
345 306 239 136 54 22 4AN + FV349 315 259 145 62 26 4AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (154 deaths)Anastrozole (176 deaths)Stratified log-rank p = 0.049
All eligible patients (n=694)Overall Surv ival in S0226
![Page 35: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/35.jpg)
HR = 0.91 (95% CI 0.65-1.28)
Median OSAnastrozole 44.5 mos (95% CI 38.0-54.8)
Combination 49.6 mos (95% CI 37.9-71.2)
0.00
0.25
0.50
0.75
1.00
Over
all S
urvi
val
139 125 100 59 24 10 2AN + FV141 125 101 54 28 13 3AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (63 deaths)Anastrozole (68 deaths)
Log-rank p = 0.59
Prior adjuvant tamoxifen (n=280)Overall Surv ival in S0226
![Page 36: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/36.jpg)
HR = 0.74 (95% CI 0.56-0.98)
Median OSAnastrozole 39.7 mos (95% CI 33.1-43.9)
Combination 47.7 mos (95% CI 43.4-58.3)
0.00
0.25
0.50
0.75
1.00
Over
all S
urvi
val
206 181 139 77 30 12 2AN + FV208 190 158 91 34 13 1AN
N at risk
0 12 24 36 48 60 72Months since registration
Anastrozole + Fulvestrant (91 deaths)Anastrozole (108 deaths)
Log-rank p = 0.0362
No prior adjuvant tamoxifen (n=414)Overall Surv ival in S0226
![Page 37: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/37.jpg)
![Page 38: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/38.jpg)
Prior tamoxifen as a predictive factor?
• Overall planned analysis is highly significant
• Unplanned analysis by prior tamoxifen may suggest benefit only in the tamoxifen naive group
• Prior tamoxifen use is confounded with time between adjuvant diagnosis and metastatic diagnosis
• Need to better understand other possible predictive factors since the prior tamoxifen factor could be a false lead from an unplanned analysis
![Page 39: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/39.jpg)
Forest Plot
Ov e ra l l
Pri o r ta mNo p ri o r ta m
Me a s u ra b l eNo n -me a s u ra b l e
Ag e 6 5 +Ag e < 6 5
De n o v o0 -5 y e a rs5 -1 0 y e a rs1 0 y e a rs +
Bo n e o n l yVi s c e ra lNo n -v i s c e ra l
HER2 -n e g a ti v eHER2 -p o s i t i v e
No p ri o r c h e moPri o r c h e mo
Co mb in a ti o n wo rs eCo mb in a ti o n b e tte r
Ov e ra l l HR = 0 .8 0
.4 .6 .8 1 1.2 1.4 1.6Hazard ratio
Unplanned subset analysisPFS treatment hazard ratio with 95% confidence interval
![Page 40: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/40.jpg)
S0226 Toxicity: Grade 4 and 5• Three patients on the combination had grade 5
toxicities:
– two had pulmonary embolism
– one had cerebrovascular ischemia
• Two other patients on the combination had grade 4 toxicities:
– one had pulmonary embolism
– one had neutropenia and lymphopenia
• Four patients on anastrozole alone had Grade 4 toxicities (thrombosis/embolism, arthralgia, thrombocytopenia, dyspnea)
![Page 41: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/41.jpg)
S0226 Toxicity• Grade 3 toxicities:
– 46 (13%) on the combination
– 38 (11%) on anastrozole alone
• Includes musculo-skeletal pain, fatigue, hot flashes, mood alterations and gastrointestinal symptoms with frequency 1-4%
• Adverse events did not differ significantly by treatment group
• Few patients went off treatment early due to adverse events or side effects (anastrozole alone 4; combination 11)
![Page 42: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/42.jpg)
First-Line Hormonal Agent Phase-III Studies in Breast Cancer: Overall Survival
Study N Control Arm (months)
Experimental Arm (months)
HR for OS P-value
S0226 694 Anastrozole (→fulvestrant
(41.3)
Anastrozole + Fulvestrant
(47.7)
0.80 0.049
Bergh SABCS 2009
514 Anastrozole
(38.2)
Anastrozole + Fulvestrant
(37.8)
1.00 1.00
Nabholtz 2003 Eur J C
1021 Tamoxifen (40.1)
Anastrozole(39.2)
0.97 ?
Mouridsen 2003 JCO
916 Tamoxifen (30)
Letrozole (34)
? 0.53
Paridaens JCO 2008
371 Tamoxifen (43.3)
Exemestane (37.2)
1.04 0.82
Howell JCO 2004
587 Tamoxifen(38.7)
Fulvestrant(36.9)
1.29 0.04
![Page 43: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/43.jpg)
S0226 Conclusions:• The combination of anastrozole and fulvestrant
improves PFS and OS, the primary and secondary endpoints, respectively, in first-line therapy of hormone receptor positive breast cancer in postmenopausal women
• The toxicity of the combination treatment is comparable to single agent treatment though Grade 5 toxicity was seen only with the combination
![Page 44: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/44.jpg)
![Page 45: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/45.jpg)
CLEOPATRA
AVEREL
![Page 46: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/46.jpg)
![Page 47: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/47.jpg)
![Page 48: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/48.jpg)
![Page 49: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/49.jpg)
![Page 50: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/50.jpg)
![Page 51: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/51.jpg)
![Page 52: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/52.jpg)
![Page 53: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/53.jpg)
![Page 54: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/54.jpg)
![Page 55: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/55.jpg)
![Page 56: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/56.jpg)
![Page 57: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/57.jpg)
![Page 58: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/58.jpg)
![Page 59: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/59.jpg)
![Page 60: SABCS 2011 Metastatic Breast Cancer Shiuh-Wen Luoh MD PhD Clinical Associate Professor](https://reader031.fdocuments.in/reader031/viewer/2022011717/5681656e550346895dd80208/html5/thumbnails/60.jpg)