Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerNeoadjuvant versus adjuvant treatment of HER2-positive tumors
3:14 minutes.
TRANSCRIPTION:
DR MAMOUNAS: In our practice, we pretty much exclusively treat most patients in the neoadjuvant setting with HER2-positive disease based on this high pathologic response rate. So I would prefer to use the neoadjuvant setting, because of the approval and because of the benefits that we get from inducing pathologic complete response in a large proportion of patients. But as Kim mentioned, if somebody gets to us after the surgery and would have met the criteria for neoadjuvant TCHP or neoadjuvant pertuzumab regimen, we would treat them with that. And we have done it a couple of times now. DR LOVE: So that means that, if the patient, preop, had a tumor greater than 2 centimeters, was node-positive and didn’t get neoadjuvant therapy, you would feel comfortable using it postop? DR BLACKWELL: I feel like we should offer that patient the potential benefits postop, because, typically, if they were seen in a multidisciplinary breast cancer clinic and met the criteria for neoadjuvant pertuzumab, they would get it, unless they have a cardiac problem that would limit their ability to receive any HER2. This is a fairly straightforward recommendation for, at least in our practice, which is basically that if you are facing HER2-driven or HER2-positive breast cancer, then it’s very appropriate, if not recommended, that you get your treatment in the neoadjuvant setting because of this additional increase in pathologic CR, with the pertuzumab being added. DR LOVE: Terry, in terms of criteria to use neoadjuvant therapy in the HER2-positive situation, particularly in terms of tumor size in patients with clinically negative axilla, how do you approach it? How low do you go, so to speak? DR MAMOUNAS: Yes. I mean, obviously, when it comes to the introduction of pertuzumab, you’re trying to follow the FDA Guideline. But when it comes to neoadjuvant anti-HER therapy, I think that anybody who you would consider for anti-HER therapy, I would actually think they were good candidates for neoadjuvant therapy, particularly, again, because of the high pathologic response rate. So obviously, we’re not talking about tumors that are less than 1 centimeter, particularly if they’re ER-positive, HER2-negative, where we don’t have a lot of patients in the adjuvant setting to extrapolate from. But definitely, 1 centimeter and above, and particularly ER-negative, HER2-positive patients, I feel very comfortable treating them in the neoadjuvant setting for reasons that we discussed before — potential for downstaging the disease, tailoring local-regional therapy and, actually, documenting pathologic complete response. There is also another caveat in here, and that is that although there is no documented benefit of adding something after surgery for those that don’t have a pathologic complete response, we do have a clinical trial that we actually are currently conducting, the KATHERINE trial, where patients who have residual disease with HER2-positive breast cancer after neoadjuvant chemotherapy and anti-HER therapy can be randomized to continue on trastuzumab for the remainder of one year or taking T-DM1 for the remaining of one year. So that’s a global trial that we’re conducing now along with the NRG and the NSABP and the German breast group. |