Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerNSABP trial of the 21-gene Recurrence Score in the neoadjuvant setting
2:54 minutes.
TRANSCRIPTION:
DR BLACKWELL: The most obvious candidate for neoadjuvant endocrine therapy is the patient who, because of comorbidities — not necessarily age driven, but because of comorbidities — will be a very poor candidate for chemotherapy, whether it be given in the neoadjuvant or adjuvant setting. So that’s a pretty fairly easy decision, if you need to delay the surgery. I just had a patient this week who actually had to have a stent placed and needed to be on anticoagulation for a couple of months, and so we placed her on neoadjuvant endocrine therapy for a probable Stage II. I think that’s a perfectly appropriate use of neoadjuvant endocrine therapy. DR LOVE: What about, again, Terry, the situation — I don't know how often you see it — where breast-conserving surgery is going to be problematic, but it might be a lot easier if you get tumor shrinkage? Is that a situation where, for example, you might do an Oncotype and, if it’s low, use hormonal therapy? DR MAMOUNAS: Yes. Absolutely. I think that’s a situation that it’s not used as much. But I think it should be used more, because you do get an insight to the biology of the tumor and find out what is the best way to downstage this tumor. In fact, Harry Bear, one of our investigators, has this clinical trial, almost like the TAILORx trial in the neoadjuvant setting, where patients with a low Oncotype score, that need to be downstaged, get neoadjuvant endocrine therapy. Those with a high Recurrence Score get neoadjuvant chemotherapy. And those with intermediate Recurrence Score, between 11 to 25, they get randomized to be downstaged with neoadjuvant endocrine or chemo. So to see, for example, what is the pathologic response and can you achieve better downstaging with chemotherapy versus endocrine therapy, even the intermediate group. DR LOVE: What about selection of endocrine therapy, if you’re going to use neoadjuvant therapy, Kim, in the premenopausal and postmenopausal patient? DR BLACKWELL: Yes. So the premenopausal patient’s a little tough for me, because we know that the optimal endocrine combination, at least in my mind, is extreme estrogen deprivation, kind of shutting down ovarian production of estrogens, as well as an aromatase inhibitor. In postmenopausal women, aromatase inhibitors would be my preferred. And that makes it a little bit even more tricky to think about incorporating endocrine therapy in the neoadjuvant setting, the premenopausal women, because we know we can’t effectively shut down ovarian production of estrogen for at least 4, if not 6 weeks if you’re using an LHRH agonist. So that makes it a subpopulation based on menopausal status that again makes it, at least in my mind, very challenging to offer neoadjuvant endocrine therapy. You can certainly offer neoadjuvant tamoxifen, but again, you’re talking about a situation where steady state’s not reached for at least 4 weeks. And in those patients, if they can go to the OR, that might be the more appropriate choice. |