DR MAMOUNAS: My bias is probably towards neoadjuvant chemotherapy for triple-negative disease. And then I have to exclude, essentially, patients who probably do okay with surgery first, but then they’ll still get chemotherapy, and obviously excluding those who may not need chemotherapy, like microinvasive disease, mostly DCIS. For those patients, obviously, we’ll do surgery first. But anybody with over a centimeter, the possibility they’ll get neoadjuvant chemotherapy — not to say that we give neoadjuvant chemotherapy to everybody with 1 centimeter. Certainly, 2 centimeters, for sure, they get neoadjuvant chemotherapy. But even 1 to 2 centimeters, sometimes you can make that decision if you want to temporize, in terms of the time of the surgery, genetic testing in triple-negative patients, you can give neoadjuvant chemotherapy while you sort all this out. There’s nothing wrong, because you’re going to give pretty much the same chemotherapy afterwards.

DR BLACKWELL: The hardest decision I make in the triple-negative space as a medical oncologist is, when do you incorporate an anthracycline for smaller tumors that are node-negative? And so it’s not infrequent to see — the hardest patient in all the subsets I see is the 2-cm, node-negative breast cancer patient. And we’ll assume they’ve had really good axillary imaging but not a sentinel lymph node.

So there’s circumstances where a 1-cm triple-negative, I might consider giving TC. And in that case, I actually prefer to do it in the neoadjuvant setting, because I’ll give TC, 4 cycles, and it’s both age spectrums. I’ll do this in the very, very young woman and older women, because you can give the 4 cycles of TC and, in this case, see what the response is. And usually it’s quite good. And then we just take the patient to the OR. If they have residual disease, I’ll contemplate talking about an anthracycline.

And so I think that the smaller triple-negative tumors, whether it’s the neoadjuvant or the adjuvant, we really — that’s the decision-making, is, do you give a second-generation TC or do you give a third-generation dose-dense or TAC? And I actually think the neoadjuvant setting, that’s probably one of the very rare circumstances where I’ll use the neoadjuvant response to tailor adding the anthracycline or not.

Now, there are some medical oncologists who give third-generation chemo to the smallest triple-negative breast cancer. I’m not necessarily convinced that that’s been proven, because many of the triple-negative tumor studies required at least 1 centimeter of disease. And so I think this is a subset of small tumors that are triple-negative where the neoadjuvant approach is actually quite helpful.

Local disease control and neoadjuvant treatment

Neoadjuvant treatment of HER2-positive tumors

Neoadjuvant treatment of triple-negative tumors

Neoadjuvant treatment of ER-positive, HER2-negative tumors

Other issues in neoadjuvant treatment