DR LOVE: There’s another issue that’s really interesting, this case brings out, and that is, the lady had a pretty large tumor, 2 of them, actually. One of them was 4 centimeters. I think it’s really interesting that she was offered the neoadjuvant neoMONARCH study looking at endocrine therapy plus a CDK4/6 inhibitor, abemaciclib. But if, for example, she needed to have tumor shrinkage in order to have breast-conserving surgery or maybe the tumor was 5 or 6 centimeters, she would have gotten chemo. And yet now we see that she’s got a low Recurrence Score tumor. So if she was just going to get nontrial neoadjuvant therapy, should she have had a genomic assay and let that guide the decision?

DR HURVITZ: You’re bringing up 2 really good points. The first one is neoadjuvant chemotherapy in patients with tumors like hers rarely has a big impact. Path CR rates are on the order of 7% or less with chemotherapy and not much better with hormonal therapy alone. So I didn’t feel that there was a conflict there for this patient, because she had a low-grade tumor and not a high proliferation index. And her, in particular, she had avoided having mammograms done. I think the prior one had been 3 years prior. So I think this was just an indolent tumor that she just missed.

In terms of the neoMONARCH study, that study allows you to give the patient adjuvant chemotherapy, so, for example, if she were progressing, we could give it before surgery if we needed to. The study doesn’t disallow that. And then after surgery, you can do whatever is clinically indicated. But your point about doing a genomic assay in a patient before neoadjuvant therapy is a good one.

And, in fact, in patients who I’ve put on this clinical trial, I’ve had 1 patient go to surgery, and she had 3 centimeters of residual tumor found at the time of surgery after having 4 months of endocrine therapy and CDK4/6 inhibitor. And the question became, do we do chemo? And so you don’t want to send the Oncotype DX on a patient’s tumor after they’ve had endocrine therapy. You want to send it on the original biopsy, because that change in Ki-67 is going to change the readout. And in the neoadjuvant setting, I think it’s a good idea to be looking at the Recurrence Score or other genomic marker to help gauge benefit of chemo.

DR LOVE: Yes, in that same survey that we did, I was really surprised. I think about a third or more of the investigators were using a genomic assay in ER-positive, HER2-negative in the neoadjuvant situation, almost all Oncotype. So I guess some people — and you’re saying sometimes you do that also?

DR HURVITZ: Uh-huh. Absolutely.

DR LOVE: One other thing about genomic assays — and I’ve seen data with Oncotype suggesting that tumor for tumor, Oncotype is used less in older patients. And I kind of was wondering whether or not maybe we don’t consider chemotherapy enough in the woman who’s 70 to 75 years old. And that the little old lady that we go, oh, we don’t want to give chemo to, if we knew had a high Recurrence Score, for example, we might be much more motivated to do it, particularly a less-toxic, nonanthracycline regimen.

DR HURVITZ: Right.

Genomic assays and (neo)adjuvant treatment decision-making

Early-stage breast cancer in the adjuvant and neoadjuvant settings

Management of metastatic breast cancer (mBC)

CDK4/6 inhibitors for the treatment of breast cancer

Checkpoint inhibitors and other novel immunotherapeutic approaches to breast cancer

Triple-negative and BRCA mutation-positive breast cancers