Editor’s Note: The expert voting on key issues for the 2025 edition of the Guidelines and Standards for Breast Cancer Diagnosis and Treatment (Essential Version), also known as the CBCS Little Red Book, organized by the Chinese Anti-Cancer Association and the Chinese Medical Association’s Oncology Branch, has concluded. The new version is on the horizon! Oncology Frontier interviewed several prominent members of the advisory board who participated in the voting, including Prof. Yiding Chen, Prof. Hengyu Li, Prof. Man Li, Prof. Shu Liu, Prof. Yongsheng Wang, and Prof. Jian Zhang, to provide insights into the potential updates in the 2025 edition.

Recently, the 18th National Breast Cancer Conference and the 19th Shanghai International Breast Cancer Symposium (SIBCS 2024) took place in Shanghai, along with the 4th Controversy & Consensus Consortium (3C) Summit on clinical practice in Chinese breast cancer. During the event, experts in breast cancer and patient representatives discussed and voted on the 2025 updates for the CBCS Little Red Book, covering 58 topics that span early breast cancer pathology, surgery, adjuvant treatment, advanced breast cancer comprehensive treatment, quality of life, and medical ethics, generating widespread anticipation among scholars.

Prof. Yiding Chen

The Second Affiliated Hospital Zhejiang University School of Medicine

• Expected Update 1: Patients with 1-2 positive sentinel lymph nodes may be exempt from axillary lymph node dissection, regardless of whether they undergo breast-conserving or total mastectomy.
• Expected Update 2: Following neoadjuvant therapy in cN0-cN1 and isolated tumor cells (ITC), patients may be considered for exemption from sentinel lymph node dissection, with axillary radiotherapy as an alternative.
• Expected Update 3: CDK4/6 inhibitor ribociclib may be recommended for intensified adjuvant therapy in high-risk HR+/HER2- breast cancer patients.
• Expected Update 4: Prophylactic contralateral mastectomy is not recommended for patients carrying BRCA mutations.

Prof. Hengyu Li

Shanghai Changhai Hospital, Naval Medical University

• Expected Update 1: Routine BRCA genetic testing should be conducted in breast cancer patients to implement personalized treatment strategies.
• Expected Update 2: BRCA genetic testing should primarily focus on BRCA1 and BRCA2, while considering over ten additional susceptibility genes associated with hereditary risk.

Prof. Man Li

The Second Hospital of Dalian Medical University

• Expected Update: For HR+/HER2- advanced breast cancer that has progressed after CDK4/6 inhibitor treatment, gene testing should guide therapy choices: PI3K inhibitors for PIK3CA mutations, AKT inhibitors for PI3KCA/AKT/PTEN mutations, oral SERDs for ESR1 mutations, PARP inhibitors for BRCA1/2 mutations, and possible cross-line CDK4/6 inhibitors in the absence of gene mutations. mTOR inhibitors and HDAC inhibitors are also viable late-line options.

Prof. Shu Liu

The Affiliated Hospital of Guizhou Medical University

• Expected Update 1: A new step-down treatment strategy may be introduced for lymph node-positive breast cancer patients.
• Expected Update 2: The distinction of HER2 ultra-low expression as a separate group in pathology remains controversial.

Prof. Yongsheng Wang

Shandong Cancer Hospital

• Expected Update 1: For T1N0 Luminal-type breast cancer patients over 70 with comorbidities or those with completely resected ductal carcinoma in situ (DCIS) without microinvasion, sentinel lymph node biopsy may be omitted.
• Expected Update 2: In postmenopausal HR+/HER2- breast cancer patients with tumors ≤2 cm and negative axillary lymph nodes, sentinel lymph node biopsy may be omitted after breast-conserving surgery.
• Expected Update 3: Patients with initial cN0 status and sentinel lymph node micrometastases following neoadjuvant therapy may be exempt from axillary lymph node dissection and instead receive axillary radiotherapy.
• Expected Update 4: For initial cN1 patients with isolated tumor cells (ITC) in sentinel lymph nodes post-neoadjuvant therapy, approximately 30% may still have non-sentinel lymph node positivity or macrometastases, thus recommending continued axillary lymph node dissection.

Prof. Jian Zhang

Fudan University Shanghai Cancer Center

• Expected Update 1: The classification of HER2 low and ultra-low expression as distinct groups in pathology remains a matter of debate.
• Expected Update 2: Precision testing may become a foundational principle in the treatment of advanced breast cancer.
• Expected Update 3: For HR+ advanced breast cancer, treatment sequence and biomarkers for AKT inhibitors capivasertib, HDAC inhibitors chidamide and entinostat, and oral SERD elacestrant are expected to be further defined.
• Expected Update 4: In HER2-positive advanced breast cancer, the combination of eribulin with dual-targeted therapy (trastuzumab and pertuzumab) may be considered as a first-line standard treatment.
• Expected Update 5: For triple-negative breast cancer, a unified CPS (Combined Positive Score) standard in various immunotherapy studies may be anticipated.

Anticipated 2025 Updates Await Final Review

The 2025 edition of the CBCS Little Red Book is set for release, but further consultation and in-depth discussion by the guideline committee and expert advisory group are needed to finalize which key points will be included in the published document.

The CBCS Little Red Book 2025 edition release event, coinciding with the Shanghai Breast Cancer Annual Conference, is scheduled for December 21, 2024, in Shanghai. Stay tuned for more updates!