Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerNeoadjuvant treatment of ER-positive, HER2-negative tumors
4:17 minutes.
TRANSCRIPTION:
DR MAMOUNAS: So if somebody presents with ER-positive, HER2-negative disease and she has a small tumor, she’s a lumpectomy candidate, she has a clinically negative axilla, the default position is probably to offer surgery first. Take the tumor out, do a sentinel node biopsy. If negative, obviously, not dissect the axilla. If positive, with the Z11 criteria, probably not dissect the axilla, either. And in that case, then go on to order an Oncotype DX test to find out if they’re candidates for chemotherapy, if they’d benefit from chemotherapy, and go down that path. When it gets a little trickier is when there’s a bigger tumor that you have to downstage somewhat to offer breast conservation — and then we talked about whether you can use neoadjuvant endocrine therapy, maybe incorporate the Oncotype up front to make that decision, versus neoadjuvant chemotherapy, and also, for patients who have clinically positive nodes or maybe even pathologically positive nodes by ultrasound — in other words, abnormal nodes by ultrasound with pathological biopsy. That’s actually a pretty tricky situation, because the more diligently we look to the axilla, we’ll find metastasis that otherwise, it’s in a clinically node-negative patient, where you can still follow the Z11 paradigm and not necessarily dissect their axilla. So don’t feel compelled to offer neoadjuvant chemotherapy for somebody with that presentation. Although, if it’s a clinically positive axilla, obviously, they wouldn’t have fallen into that category. And then you can entertain some form of neoadjuvant therapy for those patients. DR LOVE: Anything to add to that? DR BLACKWELL: Yes. I don’t think there’s any harm to sending these patients to a medical oncologist, with the exception of sending them to the medical oncologist with the expectation that they will definitely get something to shrink their tumor prior to surgery. And I’ve had that situation arise a couple of times, where the patient really cannot decide what kind of surgery they want or they’re hesitant to have surgery or they need, quote, time to digest what’s going on. And frequently, then they come to see me with the expectation that I’ll somehow delay the time. And then these patients facing tumor where they can just go to the OR up front, small tumor, clinically node — axilla. I think sending them to the medical oncologist with the expectation that they will get something to shrink their tumor is probably a bit misleading. And then I have to say, “No, you go” — it puts the patient in the middle. “You go back to your surgeon, because really I need the tumor size and the node status and the Oncotype to make treatment decisions. I’m not even convinced you’re going to need chemotherapy, so go on back.” I think that’s the time where you really need to be careful about what, as a surgeon, what expectations you’re setting for the patient when they go to see a medical oncologist. Frequently, as we all know, the patient looks up medical oncologist on the internet, they think I’m the chemotherapy doctor. So by the time they get to my office from the surgeon’s, they’re thinking the worst. Right? The surgeon’s sending them to me because they need chemo or the surgeon’s sending them to me because I have to do something before surgery. So setting a — “This is a fact-finding mission. I just want you to meet your whole team,” those are probably better auspices to send the small, ER-positive, node-negative patient to the medical oncologist, kind of set that expectation. Otherwise, by the time the patient gets to the medical oncologist’s office, they’ve whipped themselves into a frenzy, because they think they’re coming to see me because they have to have chemotherapy. DR MAMOUNAS: So we see a lot of our patients in our multidisciplinary clinic, so they always see the surgeon, medical oncologist and radiation oncologist in the same setting. And we almost, like, up front all of us have decided how we approach these patients. So if they have small, ER-positive, HER2-negative, we’ll go in as the surgeon first. You tell them, “You probably need surgery.” That gets reinforced by medical oncology. They tell them about the possible Oncotype down the road and chemotherapy or not. And so the patient is actually at ease with the decision, because they know exactly that everybody on the team agrees. On the opposite side of things, if somebody has a triple-negative or HER2-positive, we usually have decided up front that this patient’s going to get neoadjuvant chemotherapy. And it’s presented to them that way from the beginning. |