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Strategies for subtypes—dealing with the diversity ofbreast cancer: highlights of the St Gallen InternationalExpert Consensus on the Primary Therapy of EarlyBreast Cancer 2011
A. Goldhirsch1*, W. C. Wood2, A. S. Coates3, R. D. Gelber4, B. Thu¨rlimann5, H.-J. Senn6 & Panelmembers 1International Breast Cancer Study Group, Department of Medicine, European Institute of Oncology, Milan, Italy; 2Department of Surgery, Emory University School ofMedicine, N. E. Atlanta, USA; 3International Breast Cancer Study Group and University of Sydney, Sydney, Australia; 4International Breast Cancer Study Group
Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA; 5Breast Center,
Kantonsspital St Gallen, St Gallen; 6Tumor and Breast Center ZeTuP, St Gallen, Switzerland
Received 21 April 2011; accepted 23 May 2011
The 12th St Gallen International Breast Cancer Conference (2011) Expert Panel adopted a new approach to the
classification of patients for therapeutic purposes based on the recognition of intrinsic biological subtypes within the
breast cancer spectrum. For practical purposes, these subtypes may be approximated using clinicopathological rather
than gene expression array criteria. In general, systemic therapy recommendations follow the subtype classification.
Thus, ‘Luminal A’ disease generally requires only endocrine therapy, which also forms part of the treatment of the
‘Luminal B’ subtype. Chemotherapy is considered indicated for most patients with ‘Luminal B’, ‘Human Epidermal
growth factor Receptor 2 (HER2) positive’, and ‘Triple negative (ductal)’ disease, with the addition of trastuzumab in
‘HER2 positive’ disease. Progress was also noted in defining better tolerated local therapies in selected cases without
loss of efficacy, such as accelerated radiation therapy and the omission of axillary dissection under defined
circumstances. Broad treatment recommendations are presented, recognizing that detailed treatment decisions need
to consider disease extent, host factors, patient preferences, and social and economic constraints.
Key words: adjuvant therapies, early breast cancer, St Gallen Consensus, subtypes
countries and a worldwide faculty representing all relevantdisciplines. After presentation of recent research findings,
It is no longer tenable to consider breast cancer as a single
a 51-member Expert Panel (see Appendix 1) considered
disease. Subtypes can be defined by genetic array testing [1–3]
a number of questions in order to arrive at treatment
or approximations to this classification using
recommendations for the immediate future. As in previous St
immunohistochemistry [4–7]. These subtypes have different
Gallen conferences , the Panel was charged with assessing
epidemiological risk factors [8, 9], different natural histories
the evidence, but also advising on the basis of expert opinion
[10–12], and different responses to systemic and local therapies
on those questions where the evidence was ambiguous or
[13–17]. These differences imply that clinicians managing
lacking. For the first time, this conference included an explicit
breast cancer should consider cases within the various distinct
approach to management of conflicts of interest (see
subtypes in order to properly assess the relevant evidence and
arrive at appropriate therapeutic advice.
Evidence was presented to support a less aggressive approach
to axillary surgery in defined circumstances and the use of more
convenient equally effective approaches to radiation therapy.
For systemic therapy, the emphasis of this year’s consensus was
The 12th International Breast Cancer Conference in March
to reach recommendations within each of the biological
2011 brought together some 4300 participants from 96
subtypes, since these already incorporate many of the riskfactors and response predictors previously considered
*Correspondence to: Prof. A. Goldhirsch, International Breast Cancer Study Group,
separately. Disease extent, host factors, patient preferences, and
Department of Medicine, European Institute of Oncology, Via Ripamonti 435, 20141
Milan, Italy. Tel: +39-02-57489439; Fax: +39-02-94379273;
economic and social factors inevitably impact the choice and
delivery of care. In general, the recommendations are intended
to guide therapy considerations outside clinical trials in
See Appendix 1 for members of the Panel.
ª The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.5), which permitsunrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
communities with reasonable levels of available resources, but
noting where possible the availability of alternatives, whichmight be only marginally less effective but less expensive.
More than 100 questions were circulated and agreed among
This report will first review the new findings presented at the
Panel members before the meeting. These were presented
meeting (Table 1) and then proceed to summarize the
during the final session of the conference. Panel members had
deliberations of the Panel, bringing these together to form
the opportunity to comment, and then voted electronically
either yes or no on each question, with the option to abstainif they felt uninformed or conflicted. The detailed votesare not presented here: Rather, verbal descriptions of the
extent of agreement or disagreement are given in the
New results from clinical trials supported the safety of omitting
axillary dissection not only in patients with a negative sentinelnode biopsy  but also in patients with a clinically node-
negative axilla but pathological macrometastatic involvementof one or two sentinel nodes in the context of breast-conserving
The Panel was clearly of the view that the routine use of
surgery with tangential field radiation therapy . This
immunohistochemistry to look for low-volume metastatic
continues a trend of reduced surgical extent without loss of
disease in sentinel nodes was not indicated, since metastases
efficacy, which dates back to the breast-conserving approaches
shown only by immunohistochemistry would not alter
pioneered by Veronesi  and Fisher .
management. Furthermore, isolated tumor cells, and even
Similarly, recent studies in radiation therapy have
metastases up to 2 mm (micrometastases) in a single sentinel
demonstrated the safety and efficacy of abbreviated schedules
node, were not considered to constitute an indication for
for improved patient convenience and the use of partial breast
axillary dissection regardless of the type of breast surgery
irradiation (PBI) under certain defined circumstances. These
carried out. The Panel accepted the option of omitting axillary
dissection for macrometastases in the context of lumpectomyand radiation therapy for patients with clinically node-
negative disease and 1–2 positive sentinel lymph nodes as
reported from ACOSOG trial Z0011 with a median follow-up
Analysis of gene expression arrays has resulted in the
of 6.3 years . The Panel, however, was very clear that this
recognition of several fundamentally different subtypes of
practice, based on a specific clinical trial setting, should not be
breast cancer . Because it is not always feasible to obtain gene
extended more generally, such as to patients undergoing
expression array information, a simplified classification, closely
mastectomy, those who will not receive whole-breast
following that proposed by Cheang et al. , has been adopted
tangential field radiation therapy, those with involvement of
as a useful shorthand. Subtypes defined by clinicopathological
more than two sentinel nodes, and patients receiving
criteria are similar to but not identical to intrinsic subtypes and
represent a convenient approximation. As summarized in
Table 2, this approach uses immunohistochemical definition ofestrogen and progesterone receptor, the detection of
overexpression and/or amplification of the human epidermal
The Panel considered accelerated whole-breast radiotherapy to
growth factor receptor 2 (HER2) oncogene, and Ki-67 labeling
be an acceptable option in select patients: In particular, the
index, a marker of cell proliferation, as the means of identifying
Panel was divided about the use of this approach in the
presence of extensive vascular invasion.
Clearly, this clinicopathological classification requires the
Partial breast irradiation (PBI) as definitive treatment in
availability of reliable measurements of its individual
selected patients was supported by almost half of the Panel and
components. Guidelines have been published for estrogen and
by a strong majority for patients above the age of 70. There was
progesterone receptor determination  and for the
considerable uncertainty about its use in lymphoma survivors
detection of HER2 positivity . For clinical decision
who had previously undergone mantle field irradiation, where
making, the Panel supported using the US Food and Drug
out-of-quadrant second cancers’ risks are considerable and for
Administration definition of HER2 positivity based on the
any patient groups different from the current eligible population
eligibility criteria for HER2 status determination from the
in PBI trials. The Panel generally accepted PBI as an alternative to
pivotal clinical trials [80, 81]. It was noted that clarifications
conventional external beam boost to the tumor bed.
to the ASCO/CAP guidelines were in preparation, and these
Post-mastectomy radiation therapy was strongly supported
have subsequently been published . Ki-67 labeling index
for patients with four or more axillary lymph nodes involved.
presents more substantial challenges, but important guidelines
While not in general favoring irradiation for those with lesser
for this test are under development [7, 83–85]. In the
nodal involvement, the Panel by a slim majority favored
proposed classification, Ki-67 labeling index is chiefly
post-mastectomy radiation for patients younger than 45 years
important in the distinction between ‘Luminal A’ and
with 1–3 positive nodes and for patients at any age with
‘Luminal B (HER2 negative)’ subtypes. If reliable Ki-67
extensive vascular invasion in two or more blocks in
labeling index assessment is not available, some alternative
conjunction with 1–3 positive nodes.
measure of proliferation such as a histological grade may be
A majority of the Panel supported radiation after complete
excision of ductal carcinoma in situ (DCIS) but was prepared to
Table 1. Recent research findings presented at the 12th International Conference on Primary Therapy of Early Breast Cancer and their implications forpatient care
Status of research/implications for patient care
Several studies have underlined the safety of more conservative
approaches to the surgery of the axilla. If sentinel lymph nodes areclear, axillary dissection can be omitted . The ACOSOG trial Z0011for patients with a clinically node-negative axilla who underwentlumpectomy and tangential whole-breast irradiation showed at amedian follow-up of 6.3 years that axillary dissection can be omittedwithout adversely affecting prognosis even in the presence of one ortwo positive sentinel nodes .
Radiation therapy—partial breast irradiation
A randomized trial of targeted intraoperative radiotherapy yielded results
closely similar to conventional whole-breast irradiation . It isnoteworthy that in this study, 14% of the targeted intraoperativeradiotherapy group also received external beam radiotherapy andthe median follow-up in the study is 2.5 years. A single institutionseries of 1822 patients treated with breast-conserving surgery hasdocumented excellent local control with intraoperative electron
beam therapy in selected patients .
Radiation therapy—abbreviated (hypofractionated Long-term results of the Canadian randomized trial in pT1,2 N0
patients largely treated without adjuvant chemotherapy at a medianfollow-up of 12 years show similar locoregional control, survival,tolerability, and cosmesis for a 16 fraction regimen compared with a
25 fraction conventionally fractionated whole-breast radiotherapydelivered without external beam boost . Similar results have beenreported from the UK START trial at a median follow-up of 6 yearsusing a 15 fraction regimen .
In the presence of tumor defects in homologous recombination DNA
repair, inhibition of the PARP enzyme system may result in ‘syntheticlethality’ and increased cell kill . This is particularly well seen in carriersof BRCA1 and BRCA2 mutations. In such patients, single-agent PARP inhibitors,such as olaparib, produce substantial tumor responses. Other cases of triple-negative
disease seldom respond to single-agent PARP inhibition . In such patients,DNA disrupting cytotoxic agents are being investigated in combination with PARP inhibitors.
Double inhibition of HER2 by agents with differing mechanisms of action has
been shown to be superior to single-agent therapy in neoadjuvant studies [27, 28],a concept being tested in the postoperative adjuvant setting in the ongoing ALTTOstudy. The further study of the mechanism of action of trastuzumab has clarified arole for antibody-dependent cell-mediated cytotoxicity .
Endocrine therapy in postmenopausal patients
Direct comparison between 5 years of adjuvant exemestane and anastrozole
yielded comparable results, suggesting that exemestane provides an alternativearomatase inhibitor for up-front use .
Adjuvant use of zoledronic acid did not improve disease-free survival in a broad
population in the AZURE trial . Subset analysis of this study showed anapparent benefit in postmenopausal patients and no benefit in premenopausalwomen. By contrast, the ABCSG 12 trial showed a disease-free survival benefitassociated with the use of zoledronic acid among premenopausal patients, allof whom received GnRH analog . These data raise the hypothesis that anantitumor effect of bisphosphonates might depend upon a low estrogenenvironment. This hypothesis remains to be tested in further clinical trials.
Definition of intrinsic subtypes has proved efficient in defining prognosis for
breast cancer patients . Currently, there are no data from phase III trials ontheir role as predictive tools for chemotherapy benefit. Gene expression arraysare reproducible and quantitative, but cost considerations limit their wideavailability. An approximation of gene expression array results is now possibleusing formalin-fixed paraffin-embedded material .
Status of research/implications for patient care
Proliferative or immune signatures are associated with good chemotherapy
response [34–37]. In neoadjuvant therapy, a stromal signature is associatedwith a reduced response, while a lymphocytic infiltrate predicts for a higherresponse rate [38, 39].
Multiple targets for successful treatments
The large and growing number of agents targeting specific mutations suggests
the eventual need for individual mutational analysis of each tumor to select acombination of agents to block multiple pathways .
Overcoming resistance to endocrine therapies
An improved understanding of the mechanisms of endocrine therapy resistance
includes the role of growth factors, integrins, stress kinases, and molecularpathways including PI3K/AKT and MEK/MAPK . Overcoming endocrinetherapy resistance may, therefore, require inhibition of multiple escape pathwaysselected by biopsy of resistant tumors to confirm the mechanisms of resistance,which are active in each.
Treatment of germline genetic predisposition
Of the 394 genes, which have been causally implicated in human cancer, some 10%
are transmitted in the germline leading to increased susceptibility . Of these, the
BRCA1 and BRCA2 have been best studied, but others include TP53, PTEN, andCDH1, all of which can increase the risk of breast cancer. BRCA1- andBRCA2-associated breast cancer is sensitive to cross-linking agents such as cisplatin, but data from randomized comparisons with standard chemotherapy agents are awaited.
Host factors including obesity and hyperinsulinemia are associated with increased
risk of breast cancer and recurrence of breast cancer. Retrospective studies indicatethat diabetic patients receiving metformin have a lower incidence of cancercompared with diabetic patients not receiving this agent .
Treatment with beta carotene, vitamin A, and vitamin E may increase mortality.
The potential role of vitamin C and selenium on mortality remains inconclusive .
Fenretinide showed reduced breast cancer incidence in young women .
The relationship between vitamin D levels and breast cancer risk or prognosisis controversial .
A recent analysis of the NSABP B-30  confirmed previous observations from
IBCSG 13-93  that amenorrhea following chemotherapy was associatedwith substantial benefit in disease-free survival. On reanalysis of the NSABPtrial using the landmark method, as in the IBCSG study, this effect waslimited to the subset of patients with estrogen receptor-positive disease .
The early promise of the use of bevacizumab in metastatic breast cancer seen
in the E2100 study has not translated into a survival benefit in subsequentstudies: A synthesis of these results suggests no overall survival benefit .
This has led the US Food and Drug Administration to reconsider its acceleratedapproval of bevacizumab in breast cancer.
Studies of lipotransfer have demonstrated the potential for a stromal interaction to
stimulate vessel formation, raising the possibility that obesity might have an adverseprognostic impact in cancer patients via a similar stromal interaction .
Studies of mammary stem cells suggest a synergistic role for progesterone and
RANK ligand in tumor formation . This raises the possibility of an additionalmechanism of action of clinically available RANK ligand antagonists such as denosumab .
Further studies of mouse mammary stem cells demonstrated that they are highly responsive
to steroid hormone signaling though they lack both estrogen and progesterone receptors.
This is thought to be mediated through paracrine signaling involving RANKligand .
Micro RNAs are involved in different biopathological features of breast cancer.
MER221 and MER222 are involved in resistance and response to endocrine agents,while MER205 is an oncosuppressor able to interfere with response to tyrosinekinase inhibitors of the HER family .
Status of research/implications for patient care
Tumor-infiltrating regulatory T cells stimulate mammary cancer metastases
through receptor activator (RANKL-RANK) signaling . Tumor FOXP3+ Tregcells are a major source of RANKL, which stimulates the metastatic progressionof HER2-positive RANK-expressing breast cancer cells .
The commercial scores from assays such as Oncotype DXÒ  and Mamma
PrintÒ  have been used to determine prognosis. Oncotype DXÒ has been shown topredict chemotherapy benefit among patients with hormone receptor-positive disease.
An interesting STEPP analysis  from the adjuvant trastuzumab NSABP B-31 trialexamined the degree of HER2 mRNA expression and corresponding trastuzumab benefit separatelyfor patients with estrogen receptor-positive and estrogen receptor-negative disease. The strikingfinding was that among patients with estrogen receptor-positive disease, trastuzumab benefit interms of 8-year disease-free survival was entirely confined to thosewith the higher levels of HER2 mRNA expression. In contrast, patients withestrogen receptor-negative disease derived some benefit from trastuzumab at alllevels of mRNA expression, though the quantitative benefit was greater amongthose with higher levels of HER2 .
The North Central Cancer Treatment Group adjuvant trastuzumab study (N9831)
included a randomization between trastuzumab administered either concurrentlywith or following chemotherapy. Analysis presented at the SABCS 2009 suggested asuperior disease-free survival with concurrent administration .
Targeted therapy in the neoadjuvant setting
The NOAH study  showed clear improvement in breast pathological complete
remission (bpCR) rate and event-free survival at 3 years with neoadjuvant trastuzumab forpatients with HER2-positive disease.
Studies in metastatic breast cancer and in the neoadjuvant setting have
demonstrated activity of trastuzumab and other anti-HER2 agents without chemotherapy albeit usually less than the activity seen for the combination with chemotherapy.
There are no corresponding data in the adjuvant setting. However, it may be logical topropose that anti-HER2 therapy, alone or with endocrine therapy if appropriate,may be effective in patients who for various reasons cannot receive cytotoxic therapy [64, 65].
Triple-negative breast cancer includes cases susceptible to DNA-damaging agents
such as cisplatin. Neoadjuvant studies including cisplatin have produced pCR ratesbetween 22% and 40% among unselected triple-negative cases [66, 67], while 10 of 12cases with BRCA1 mutations achieved pCR with single agent cisplatin .
Failure to achieve pCR among patients with rapidly proliferating tumors identifies a
group with a poor prognosis, which may be suitable for early trials of investigational agents .
A historical cohort of patients, who did not receive adjuvant systemic therapy in the
Danish Breast Cancer Group, were compared with the general Danishpopulation to ascertain mortality ratios associated with the diagnosis of breastcancer. In the absence of other risk factors, patients aged 50 years and older withsmall (1–10 mm) breast cancers had a risk of death comparable to thebackground population. By contrast, younger patients with similar tumorshad a significantly higher risk of death than the unaffected population .
Young patients with endocrine-responsive disease The ABCSG Trial 12 shows that premenopausal women with endocrine-responsive
disease who receive ovarian function suppression plus either tamoxifen oranastrozole continue to experience a low risk of relapse .
The EBCTCG reported similar benefit to systemic chemotherapy in all age groups
with estrogen receptor poor disease . The CALGB 49907 study showed inferiorresults for single-agent chemotherapy compared with standard first generationcombination regimens . The SWOG 8814 trial demonstrated an overall benefit toCAF followed by tamoxifen versus tamoxifen alone in postmenopausal patients withendocrine-responsive disease , though this was seen primarily among those withadverse biologic features such as quantitatively lower estrogen receptor levels,involvement of four or more lymph nodes, or high 21 gene RS .
Status of research/implications for patient care
Special histological types of breast cancer
Review of special histological types in a large institutional series suggested that
endocrine-responsive types such as tubular and cribriform carcinomas may besuitable for observation without therapy or for endocrine therapy alone. Rarevariants of lobular carcinomas (e.g. pleomorphic) and apocrine carcinomas requiretreatment according to their biological features in a manner analogous to that usedfor ductal carcinoma. The heterogeneous ‘Triple negative’ subtype includes adenoidcystic, juvenile secretory (good prognosis), medullary (intermediate prognosis), andmetaplastic (either low grade, with good prognosis; or high grade, with poor prognosis)carcinomas, for which no generalizations can be proposed .
countenance its omission for some elderly patients and those
postmenopausal patients (<55 years of age). The Panel was
almost unanimous in rejecting CYP2D6 testing to dictatechoice of endocrine therapy type.
The Panel strongly supported the clinicopathologicaldetermination of estrogen receptor, progesterone receptor,
The Panel agreed that factors arguing for the inclusion of
HER2, and Ki-67 as useful for defining subtypes, but did not
chemotherapy were high histological grade, high proliferation
support the incorporation of tests for cytokeratin 5/6 or
as measured by Ki-67, low hormone receptor status, positive
epidermal growth factor receptor/HER1 for the determination
HER2 status, and ‘Triple negative’ status in invasive ductal
of ‘basal-like’ tumors for clinical decision making. The
carcinoma of usual forms. These factors are largely captured in
endorsed clinicopathological criteria define a convenient
the tumor subtype definitions summarized in Table 2. There
alternative to formal subtyping and are likely to be refined in
was a lack of complete consensus on the threshold indication
the future. The Panel did not require multigene array definition
for inclusion of chemotherapy for patients with ‘Luminal A’ or
of tumor subtype, although there was acceptance of such
‘Luminal B (HER2 negative)’ disease. In terms of disease extent,
assays for certain indications (see below). However, the Panel
the Panel did not believe that node positivity per se was an
did recommend that the clinicopathological markers described
indication for use of chemotherapy, though a strong majority
above were generally sufficient to guide therapeutic choices.
would use it if more than three lymph nodes were involved.
Several tests are available which define prognosis [57, 58, 86].
selection of endocrine therapy in premenopausal
These may indicate a prognosis so good that the doctor and
patient decide that chemotherapy is not required. A strong
majority of the Panel agreed that the 21-gene signature
The Panel accepted tamoxifen alone or ovarian function
(Oncotype DXÒ)  may also be used where available to
suppression plus tamoxifen as reasonable, though expressing
predict chemotherapy responsiveness in an endocrine-
a preference for tamoxifen alone. In patients with
responsive cohort where uncertainty remains after
a contraindication to tamoxifen, ovarian function suppression
consideration of other tests, but the majority agreed that the
alone was accepted as a treatment, while the combination of
chemopredictive properties of the 70-gene signature
ovarian function suppression plus an aromatase inhibitor was
(MammaPrintÒ)  were not yet sufficiently established.
Trials are ongoing to clarify this role for both tests. Themajority of the Panel did not support lymphovascular invasion
selection of endocrine therapy in postmenopausal
as a sufficient indication for chemotherapy, and less than
a quarter of the Panel supported uPA/PAI1  as a predictive
The Panel was exactly equally divided about whether all
postmenopausal patients should receive an aromatase inhibitor(if available and not contraindicated) at some point in
treatment, but was more supportive of aromatase inhibitors in
The Panel strongly agreed that the ‘Luminal A’ subtype was less
the presence of involved lymph nodes. A large majority felt that
responsive to chemotherapy; that chemotherapy was less useful
selected patients could be treated with tamoxifen alone, and
in such patients; and that no preferred chemotherapy regimen
that patients could be switched to tamoxifen if intolerant to
could be defined for treatment of ‘Luminal A’ disease.
aromatase inhibitors. The Panel stressed the need to ensure that
For ‘Luminal B’ disease, the Panel considered that both
patients receiving an aromatase inhibitor were indeed
anthracyclines and taxanes should be included in the
postmenopausal, whether by clinical or biochemical criteria.
chemotherapy regimen. While the Panel could not define a single
The Panel considered that 5 years of an aromatase inhibitor
preferred chemotherapy regimen for ‘HER2 positive’ disease, the
was a sufficient duration and a majority opposed extension
majority again favored the inclusion of both anthracyclines and
even in the presence of node-positive disease or among younger
taxanes. For ‘Triple negative’ disease of the usual ductal type, the
Table 2. Surrogate definitions of intrinsic subtypes of breast cancer (4, 7)
This cut-point for Ki-67 labelling index was established by comparison
with PAM50 intrinsic subtyping (7). Local quality control of Ki-67
Genes indicative of higher proliferation are markers of poor prognosis in multiple
genetic assays (78). If reliable Ki-67 measurement is not available, some alternative
assessment of tumor proliferation such as grade may be used to distinguish
between ‘Luminal A’ and ‘Luminal B (HER2 negative)’.
Both endocrine and anti-HER2 therapy may be indicated.
ER and/or PgR positiveAny Ki-67HER2 over-expressed or amplified
HER2 over-expressed or amplifiedER and PgR absent
Approximately 80% overlap between ‘triple negative’ and intrinsic ‘basal-like’ subtype
but ‘triple negative’ also includes some special histological types such as (typical)
medullary and adenoid cystic carcinoma with low risks of distant recurrence.
Staining for basal keratins (79) although shown to aid selection of true
basal-like tumors, is considered insufficiently reproducible for general use.
*This cut-point is derived from comparison with gene array data as a prognostic factor . Optimal cut-points in Ki-67 labelling index for prediction ofefficacy of endocrine or cytotoxic therapy may vary.
**Some cases over-express both luminal and HER2 genes.
Panel again supported the inclusion of anthracyclines and
associated with pathological complete response to such therapy,
taxanes and an alkylating agent (typically cyclophosphamide),
particularly in patients with ‘HER2 positive’ and ‘Triple
but did not support the routine use of cisplatin or carboplatin. A
negative (ductal)’ tumors , which may allow earlier change
slim majority agreed that dose-dense chemotherapy  should
be considered for such patients, and the Panel was strongly
The Panel considered that the choice of neoadjuvant
opposed to the inclusion of antiangiogenic therapies at this time,
chemotherapy should be made on the same basis as applied in
while noting that further trials are ongoing.
the selection of postoperative adjuvant treatments. The Panelsupported the incorporation of an anti-HER2 drug in the
neoadjuvant therapy for patients with ‘HER2 positive’ disease,
The Panel unanimously supported the use of 1 year of
but did not support dual HER2 targeting at this point in time.
trastuzumab as standard adjuvant treatment for patients with
The Panel did not support cytotoxic neoadjuvant therapy for
‘HER2 positive’ disease, and the majority were willing to extend
tumors with low proliferation or high endocrine responsiveness.
this to patients with pT1b, but not pT1a pN0 disease.
Trastuzumab administered for <1 year  was regarded as
suboptimal if 1 year of therapy was feasible, but better than no
The Panel was almost unanimous in supporting the use of
trastuzumab if limited resources prevented its full duration use.
neoadjuvant endocrine therapy as an option for postmenopausal
While awaiting data from the ongoing HERA trial, the Panel did
patients with highly endocrine-responsive disease. If given, the
not support continuation of adjuvant trastuzumab beyond 1
Panel considered that such treatment should be continued until
year. While preferring that trastuzumab be initiated concurrently
maximal response or for a minimum of 4–8 months.
with chemotherapy, the Panel also accepted its sequential use.
The Panel did not support the use of trastuzumab withoutchemotherapy if chemotherapy could be given, but was prepared
to countenance such treatment in circumstances where
The Panel did not support the use of bisphosphonates for
chemotherapy could not be delivered.
antitumor effect in either pre-  or postmenopausal patients.
A majority of the Panel considered that neoadjuvant cytotoxic
therapy was of value beyond its role in facilitating conservative
Adjuvant tamoxifen was strongly supported, but only a slim
surgery and noted the improved prognostic information
majority would consider aromatase inhibitors in patients with
Table 3. Systemic treatment recommendations for subtypes
Few require cytotoxics (e.g. high nodal status or
Inclusion and type of cytotoxics may depend on
level of endocrine receptor expression,perceived risk and patient preference.
Cytotoxics + anti-HER2 + endocrine therapy
No data are available to support the omission of
Patients at very low risk (e.g. pT1a and node
negative) may be observed withoutsystemic adjuvant treatment.
Medullary and adenoid cystic carcinomas may
not require any adjuvant cytotoxics (if nodenegative).
*Special histological types: Endocrine responsive (cribriform, tubular, and mucinous); Endocrine nonresponsive (apocrine, medullary, adenoid cystic andmetaplastic).
contraindications to tamoxifen, such as thrombosis. The Panel
Grant No. CA75362 from the United States National Cancer
did not support extended endocrine treatment beyond 5 years
for male breast cancer. The lack of any evidence on these lattertwo points was acknowledged.
summary of systemic treatment recommendations
Aapro M., Roche (Speakers Bureau, Consultant), Novartis
The approach to treatment within breast cancer subtypes
(Speakers Bureau, Consultant), Pfizer (Speakers Bureau,
greatly simplifies the definition of therapy indications, since the
Consultant), Amgen (Speakers Bureau, Consultant), Genomic
subtypes themselves incorporate many of the risk and
Health (Speakers Bureau, Consultant), GSK (Consultant,
predictive factors used in previous consensus
Research), Genomic Health (Speakers Bureau, Consultant);
recommendations. The broad recommendations are
Albain K., Genomic Health (Speakers Bureau), Roche/
summarized in Table 3 and essentially indicate endocrine
Genentech (Speakers Bureau); Baselga J., Merck (Consultant);
therapy alone for patients with clinicopathologically classified
Bergh J., Onyx/Bayer (Consultant), AstraZeneca (Speakers
‘Luminal A’ disease (except in defined high-risk cases), chemo-
Bureau), Roche (Speakers Bureau), Novartis (Speakers
endocrine therapy for ‘Luminal B’, the addition of anti-HER2
Bureau), Pfizer (Speakers Bureau), Amgen (Speakers Bureau),
therapy in the presence of ‘HER2 positivity’, and a reliance on
TRM (Speakers Bureau), Merck (Research), Tapestry Network
chemotherapy for most patients with ‘Triple negative’ disease
(Consultant); Bertolini F., Pfizer (Research), Molmed
(e.g. those with invasive ductal carcinoma).
(Research); Bonnefoi H., Sanofi-aventis (Speakers Bureau,Consultant), Roche (Consultant), Novartis (Speakers Bureau);Brisken C., None; Burstein H., None; Castiglione M.; None;
Coates A., None; Coleman R., Novartis (Speakers Bureau),
The authors thank the participants in the 12th International
Amgen (Speakers Bureau, Consultant), Roche (Speakers
Conference on Primary Therapy of Early Breast Cancer for
Bureau, Consultant, Travel), Pfizer (Speakers Bureau); Colleoni
many useful remarks and for substantial contributions to the
M., None; Costa A., None; Curigliano G., None; Davidson N.,
process. We acknowledge the substantial contributions of Mrs.
None; DeCensi A., None; DiLeo A., AstraZeneca (Speakers
Shari Gelber and Mrs. Sabina Briner. We also thank Prof.
Bureau), GSK (Speakers Bureau), Pfizer (Speakers Bureau),
Umberto Veronesi for his guidance and Dr Franco Nole` for his
Roche (Speakers Bureau), Sanofi-aventis (Speakers Bureau),
Cephalon (Speakers Bureau); Dowsett M., AstraZeneca(Speakers Bureau, Consultant, royalties), Roche (SpeakersBureau, Consultant), GSK (Consultant), Ipsen (Consultant),
Cayar (Speakers Bureau, Consultant); Ejlertsen B., None;Forbes J., AstraZeneca (Speakers Bureau); Galimberti V., None;
Support for the conference was provided by SONK from
Garber J., Novartis (Spouse Consults); Gelber R., None; Glaus
registration fees paid by the conference attendees and by
A., None; Glick J., None; Gnant M., AstraZeneca (Speakers
Bureau, Consult, Travel), Novartis (Speakers Bureau, Consult,
Sanofi-aventis (Consultant), Novartis (Consultant), Specialize
Travel), Roche (Consult, Research, Travel), Sanofi-aventis
Thera/Abraxis (Consultant); Winer E., Genentech (Research);
(Research), GSK (Speakers Bureau); Goldhirsch A., Pfizer
(Travel), GSK (Speakers Bureau, Travel), Roche (SpeakersBureau, Travel), Ferring (Speakers Bureau); Gomis R., None;
Goodwin P., Amgen (Speakers Bureau), Novartis(Employment), Pfizer (Travel); Goss P., Novartis (Speakers
1. Perou CM, Sorlie T, Eisen MB et al. Molecular portraits of human breast tumours.
Bureau), GSK (Speakers Bureau), Novartis (Research); Harris
2. Prat A, Perou CM. Deconstructing the molecular portraits of breast cancer. Mol
J., None; Hayes D., DNAR (Speakers Bureau), Compendia
(Speakers Bureau), Chugai (Speakers Bureau), GSK (Research),
3. Parker JS, Mullins M, Cheang MCU et al. Supervised risk predictor of breast
Pfizer (Research), Novartis (Research), Veridex/J&J (Research),
cancer based on intrinsic subtypes. J Clin Oncol 2009; 27: 1160–1167.
OncImmune (Stock), Halcyon Diagnostics (Stock); Ingle J.,
4. Nielsen TO, Hsu FD, Jensen K et al. Immunohistochemical and clinical
Pfizer (Consultant uncompensated); Intra M., None; Iorio M.,
characterization of the basal-like subtype of invasive breast carcinoma. Clin
None; Jassem J., None; Jiang Z., None; Jordan V.C., None;
Karlsson P., Sanofi-aventis (Travel), AstraZeneca (Travel),
5. Blows FM, Driver KE, Schmidt MK et al. Subtyping of breast cancer by
Amgen (Travel); Kaufmann M., AstraZeneca (Consultant,
immunohistochemistry to investigate a relationship between subtype and short
Travel), Pfizer (Consultant, Travel), Novartis (Consultant,
and long term survival: a collaborative analysis of data for 10,159 cases from 12
Travel), Roche (Travel), GSK (Consultant, Travel), Amgen
studies. PLoS Med 2010; 7: e1000279.
(Consultant, Travel), Sanofi-aventis (Consultant, Travel);
6. Hugh J, Hanson J, Cheang MC et al. Breast cancer subtypes and response to
docetaxel in node-positive breast cancer: use of an immunohistochemical
Kerbel R., Taiho (Consultant), GSK (Consultant, Research),
definition in the BCIRG 001 Trial. J Clin Oncol 2009; 27: 1168–1176.
MetronomiX (Consultant), Pfizer (Research); Kuhl C., None;
7. Cheang MCU, Chia SK, Voduc D et al. Ki67 index, HER2 status, and prognosis of
Lindemann G., Sanofi-aventis (Consultant); Mandelblatt J.,
patients with luminal B breast cancer. J Natl Cancer Inst 2009; 101: 736–750.
None; Von Minckwitz G., Amgen (Consultant, Research,
8. Millikan RC, Newman B, Tse CK et al. Epidemiology of basal-like breast cancer.
Travel), BSM (Research), Chugai (Speakers Bureau), GSK
Breast Cancer Res Treat 2008; 109: 123–139.
(Research), Mundipharma (Research), Novartis (Research),
9. Phipps AI, Chlebowski RT, Prentice R et al. Body size, physical activity, and risk
Pfizer (Research), Roche (Speakers Bureau, Consultant,
of triple-negative and estrogen receptor-positive breast cancer. Cancer
Research), Sanofi-aventis (Consultant, Research), Wyeth
Epidemiol Biomarkers Prev 2011; 20: 454–463.
(Research); Morrow M., None; Namer M., Sanofi-aventis
10. Phipps AI, Buist DS, Malone KE et al. Reproductive history and risk of three
(Speakers Bureau), Cephalon (Travel); Norton L., Biogen
breast cancer subtypes defined by three biomarkers. Cancer Causes Control
(Other); Orrecchia R., None.; Osborne C.K., None; Paik S.,
GSK (Research, Travel); Partridge A., None; Penault F., None;
11. Liedtke C, Mazouni C, Hess KR et al. Response to neoadjuvant therapy and long-
term survival in patients with triple-negative breast cancer. J Clin Oncol 2008;
Perou C., University Genomics (Stock), Bioclassifier (Stock),
Roche (Consultant, Research), AstraZeneca (Consultant),
12. Dignam JJ, Dukic V, Anderson SJ et al. Hazard of recurrence and adjuvant
CancerGuides (Consultant); Piccart M., Roche (Consultant,
treatment effects over time in lymph node-negative breast cancer. Breast Cancer
Travel); Possinger K., AstraZeneca (Consultant, Travel);
Pritchard K., Boehringer (Consultant), Roche (Travel),
13. Aebi S, Sun Z, Braun D et al. Differential efficacy of three cycles of CMF followed
AstraZeneca (Consultant), Pfizer (Consultant), Abraxis
by tamoxifen in patients with ER-positive and ER-negative tumors: long-term
(Consultant); Rutgers E., None; Semiglazov V., None; Senn
follow up on IBCSG Trial IX. Ann Oncol 2011 [epub ahead of print 31 January
H.J., Roche (Travel), Takeda (Travel); Smith I.E., Roche
(Speakers Bureau, Consultant), Sanofi-aventis (Speakers
14. Albain KS, Barlow WE, Shak S et al. Prognostic and predictive value of the 21-
Bureau), GSK (Speakers Bureau), Bayer (Consultant); Sotiriou
gene recurrence score assay in postmenopausal women with node-positive,oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective
C., Merck (Consultant), Novartis (Consultant), Ipsogen
analysis of a randomised trial. Lancet Oncol 2010; 11: 55–65.
(Consultant); Stratton M., None; Thu¨rlimann B., Roche
15. Nguyen PL, Taghian AG, Katz MS et al. Breast cancer subtype approximated by
(Consultant, Stock, Research, Travel), Novartis (Stock, Travel),
estrogen receptor, progesterone receptor, and HER-2 is associated with local
Sanofi-aventis (Research), AstraZeneca (Consultant, Research),
and distant recurrence after breast-conserving therapy. J Clin Oncol 2008; 26:
Janssen (Other), BMS (Consultant); Toi M., GSK (Speakers
Bureau), Taiho (Research), Eli Lilly (Consultant); Tutt A.,
16. Wo JY, Taghian AG, Nguyen PL et al. The association between biological subtype
AstraZeneca (Travel), Sanofi-aventis (Consultant, Travel),
and isolated regional nodal failure after breast-conserving therapy. Int J Radiat
Roche (Travel), Pfizer (Consultant, Travel), BMS (Consultant,
Oncol Biol Phys 2010; 77: 188–196.
Travel), Genentech (Research); Untch M., None; Urban C.,
17. Tang G, Shak S, Paik S et al. Comparison of the prognostic and predictive
None; Veronesi P., None; Veronesi U., None; Viale G., Roche
utilities of the 21-gene recurrence score assay and Adjuvant! for women with
(Consultant), GSK (Consultant), Novartis (Travel); Vicini F.,
node-negative, ER-positive breast cancer: results from NSABP B-14 and NSABPB-20. Breast Cancer Res Treat 2011; 127: 133–142.
None; Watanabe T., Pfizer (Speakers Bureau), AstraZeneca
18. Goldhirsch A, Ingle JN, Gelber RD et al. Thresholds for therapies: highlights of
(Speakers Bureau), Asklep (Speakers Bureau), Novartis
the St. Gallen International Expert Consensus on the Primary Therapy of Early
(Speakers Bureau), BMS (Speakers Bureau), McCann Health
Breast Cancer 2009. Ann Oncol 2009; 20: 1319–1329.
(Speakers Bureau), Chugai (Speakers Bureau), Taiho (Speakers
19. Krag DN, Anderson SJ, Julian TB et al. Sentinel-lymph-node resection compared
Bureau), Janssen (Speakers Bureau), GSK (Speakers Bureau),
with conventional axillary-lymph-node dissection in clinically node-negative
Sanofi-aventis (Speakers Bureau), Takeda (Speakers Bureau);
patients with breast cancer: overall survival findings from the NSABP B-32
Wilcken N., GSK (Consultant, Travel), Roche (Consultant),
randomised phase 3 trial. Lancet Oncol 2010; 11: 927–933.
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Members of the Panel are listed below. All had a significant
73. Colleoni M. Adjuvant therapies for special types of breast cancer. Breast 2011;
input to the discussion and manuscript.
74. Veronesi U, Saccozzi R, Del VM et al. Comparing radical mastectomy with
Matti Aapro, Clinique de Genolier, 3 Route du Muids, 1272
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Kathy S. Albain, Loyola University Medical Center, Cardinal
75. Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical
Bernardin Cancer Center, Room 109, 2160 S First Ave, Maywood,
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radiation in the treatment of breast cancer. N Engl J Med 1985; 312: 665–673.
Jose´ Baselga, Massachusetts General Hospital Cancer Center,
76. Hammond ME, Hayes DF, Dowsett M et al. American Society of Clinical
55 Fruit Street, YAW 9, Boston, MA 02114, USA
Oncology/College of American Pathologists guideline recommendations forimmunohistochemical testing of estrogen and progesterone receptors in breast
Jonas Bergh, Radiumhemmet & Karolinska Oncology,
cancer. J Clin Oncol 2010; 28: 2784–2795.
Karolinska Institutet and University Hospital, 171 76
77. Wolff AC, Hammond ME, Schwartz JN et al. American Society of Clinical
Oncology/College of American Pathologists guideline recommendations for
Herve´ Bonnefoi, Institut Bergonie´ Cancer Center, Universite´
human epidermal growth factor receptor 2 testing in breast cancer. J Clin Oncol
Harold Burstein, Department of Medical Oncology/Solid
78. Wirapati P, Sotiriou C, Kunkel S et al. Meta-analysis of gene expression profiles
Tumor Oncology, Dana-Farber Cancer Institute, 450
in breast cancer: toward a unified understanding of breast cancer subtyping and
prognosis signatures. Breast Cancer Res 2008; 10: R65.
Monica Castiglione-Gertsch, Oncogynecology Unit,
79. Cheang MC, Voduc D, Bajdik C et al. Basal-like breast cancer defined by five
University Hospital, Bd. de la Cluse 30, 1211 Geneva,
biomarkers has superior prognostic value than triple-negative phenotype. Clin
80. Piccart-Gebhart MJ, Procter M, Leyland-Jones B et al. Trastuzumab after
Alan S. Coates, International Breast Cancer Study Group and
adjuvant chemotherapy in HER2-positive breast cancer. N Engl J Med 2005;
University of Sydney, Sydney, NSW 2006, Australia
Marco Colleoni, Research Unit Medical Senology, European
81. Romond EH, Perez EA, Bryant J et al. Trastuzumab plus adjuvant chemotherapy
Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
for operable HER2-positive breast cancer. N Engl J Med 2005; 353:
Alberto Costa, ESO—European School of Oncology, Via del
Bollo 4, 20123 Milan, Italy and Breast Unit of Southern
82. Hammond ME, Hayes DF, Wolff AC. Clinical notice for American Society of
Clinical Oncology-College of American Pathologists guideline recommendations
Giuseppe Curigliano, Division of Medical Oncology,
on ER/PgR and HER2 testing in breast cancer. J Clin Oncol 2011; 29: e458.
European Insitute of Oncology, Via Ripamonti 435, 20141
83. Viale G, Regan MM, Mastropasqua MG et al. Predictive value of tumor Ki-67
expression in two randomized trials of adjuvant chemoendocrine therapy for
Nancy E. Davidson, University of Pittsburgh Cancer Institute,
node-negative breast cancer. J Natl Cancer Inst 2008; 100: 207–212.
5150 Centre Avenue, UPMC Cancer Pavilion,
84. Viale G, Giobbie-Hurder A, Regan MM et al. Prognostic and predictive value of
centrally reviewed Ki-67 labeling index in postmenopausal women with
5th Floor, Suite 500, Pittsburgh, PA 15232, USA
endocrine-responsive breast cancer: results from Breast International Group trial
Angelo Di Leo, ‘Sandro Pitigliani’ Medical Oncology Unit,
1-98 comparing adjuvant tamoxifen with letrozole. J Clin Oncol 2008; 26:
Department of Oncology, Hospital of Prato, Piazza
Bent Ejlertsen, Department of Oncology, Bldg 4262
C. Kent Osborne, Dan L. Duncan Cancer Center, Baylor College
Rigshospitalet, 9 Blegdamsvej, 2100 Copenhagen,
of Medicine, One Baylor Plaza, Houston, TX 77030, USA
Fre´de´rique Penault-Llorca, Service d’Anatomie Pathologie
John F. Forbes, Department of Surgical Oncology, University
Mole´culaire, De´pt. RIO, Centre Jean Perrin, 58 rue
of Newcastle, Calvary Mater Hospital, ANZ BCTG, Edith
Montalembert, BP 392, 63011 Clermont-Ferrand Cedex 1,
Street Waratah, Newcastle 2298 NSW Australia
Richard D. Gelber, Department of Biostatistics and
Charles M. Perou, Lineberger Comprehensive Cancer Center,
Computational Biology, Dana-Farber Cancer Institute, 450
Departments of Genetics and Pathology, The University of
North Carolina, Chapel Hill, NC 27599, USA
Agnes Glaus, ZeTuP, Center for Tumor Detection, Treatment
Martine J. Piccart-Gebhart, Internal Medicine, Oncology,
and Prevention, Rorschacher Strasse 150, 9006 St Gallen,
Institut Jules Bordet, Rue He´ger-Bordet 1, 1000 Brussels,
John H. Glick, University of Pennsylvania, Abramson Cancer
Kurt Possinger, Universita¨tsklinikum Charite´ Campus Mitte,
Center, Perelman Center, 3400 Civic Center Blvd,
Centrum 14, M.S. Onkologie/Ha¨matologie, Charite´platz 1,
Michael Gnant, Medical University of Vienna, Department of
Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre,
Surgery, Comprehensive Cancer Center Vienna, Wa¨hringer
Ontario Clinical Oncology Group (OCOG), 2075 Bayview
Aron Goldhirsch, International Breast Cancer Study Group,
Emiel J.T. Rutgers, The Netherlands Cancer Institute,
Department of Medicine, European Institute of Oncology,
Department of Surgery, Plesmanlaan 121, 1066 CX
Via Ripamonti 435, 20141 Milan, Italy, and Swiss Center for
Breast Health, Sant’Anna Clinics, 6924 Lugano-Sorengo,
Vladimir Semiglazov, N.N. Petrov Research Institute of
Oncology, 68 Leningradskaya Street, Pesochny-2, 197758 St
Pamela Goodwin, Department of Medicine, Division of
Clinical Epidemiology, Samuel Lunenfeld Research Institute,
Ian Smith, Breast Unit, Royal Marsden Hospital and Institute
Mount Sinai Hospital and Princess Margaret Hospital,
of Cancer Research, Fulham Road, London, SW3 6JJ, UK
University of Toronto, 1284-600 University Avenue, Toronto,
¨rlimann, Breast Center, Kantonsspital St Gallen,
Paul E. Goss, MGH Cancer Center, 55 Fruit Street, Boston,
Masakazu Toi, Department of Breast Surgery, Kyoto
University Hospital, 54 Shogoin-Kawahara cho, Sakyo-ku,
Jay R. Harris, Department of Radiation Oncology, Dana-
Farber Cancer Institute, Brigham and Women’s Hospital,
Andrew Tutt, Breast Oncology Unit, Guy’s Hospital, King’s
Room 1622, 44 Binney Street, Boston, MA 02115, USA
Dan F. Hayes, Breast Care Center, University of Michigan,
Michael Untch, Department of Gynecology and Obstetrics,
Comprehensive Cancer Center, 1500 East Medical Center
Multidisciplinary Breast Cancer Center, Helios Klinikum
Berlin-Buch, Academic Hospital of the University of
James N. Ingle, Mayo Clinic Cancer Center, Women’s Cancer
Go¨ttingen, Schwanebecker Chaussee 50, 13125 Berlin,
Program, 200 First Street S.W., Rochester, MN 55905, USA
Jacek Jassem, Medical University of Gdansk, Deptartment of
Giuseppe Viale, Department of Pathology, European Institute
Oncology & Radiotherapy, Debinki Street 7, 80-211 Gdansk,
of Oncology and University of Milan, Via Ripamonti 435,
Zefei Jiang, 307 Hospital, Academy of Military Medical
Toru Watanabe, Department of Medicine, Hamamatsu
Sciences, 8 Fengtai East Avenue, 100071 Beijing, China
Oncology Center, 3-6-13 Chuo Naka-Ku , 430-0929
Per Karlsson, Department of Oncology, Institute of Selected
Clinical Sciences, Sahlgrenska Academy, Sahlgrenska
Nicholas Wilcken, Department of Medical Oncology,
University Hospital, 413 45 Go¨teborg, Sweden
University of Sydney, Westmead Hospital, Westmead 2145,
Manfred Kaufmann, Department of Gynecology, Obstetrics,
Breast Unit, J.W. Goethe University, Theodor Stern Kai 7,
Eric P. Winer, Breast Oncology Center, Dana-Farber Cancer
Institute, 450 Brookline Avenue, Boston, MA, 02115, USA
Gunter von Minckwitz, GBG Forschungs GmbH, Martin
William C. Wood, Department of Surgery, Winship Cancer
Behaim Strasse 12, 63263 Neu-Isenburg, Germany
Institute, 1365C Clifton Road, Atlanta, GA 30322, USA
Monica Morrow, Memorial Sloan-Kettering Cancer Center,
Evelyn Lauder Breast Center, 300 East 66 Street, New York,NY 10065, USA
Moise Namer, Medical Oncology, Centre Antoine Lacassagne,
33 Av. de Valombrose, 06189 Nice Cedex 2, France
Larry Norton, Memorial Sloan-Kettering Cancer Center,
Room H 901, 205 East 64th Street, Concourse Level, New
Note: details of the declared conflicts of interest are available at
Minutes of the regular Proctor City Council Meeting held September 3, 2013 in the Proctor Area Community Center Council Chambers Mayor Brenna called the meeting to order at 6:00pm. PLEDGE OF ALLEGIANCE MEMBERS PRESENT: Councilors: Jake Benson, Travis White, Jim Schwarzbauer, OTHERS PRESENT: Jim Aird, Midway Township; Jim Rohweder, City Administrator; Tim Peterson, Deputy Clerk;
Towards the Third Modernity How ordinary people are transforming the world Extracts Triarchy Press Towards the Third Modernity and… These are extracts from Towards the Third Modernity: How Ordinary People are Transforming the World. There isn’t space here to include data and examples, to develop arguments, to quote sources or list further reading. To read more about