Assisting Community-Based Oncologists and Surgeons in Making Neoadjuvant Treatment Decisions for Patients with Early Breast CancerPreoperative genomic assays in patients with ER-positive, HER2-negative tumors
3:33 minutes.
TRANSCRIPTION:
DR BLACKWELL: One of the things I’m frequently doing in my own practice is I am ordering an Oncotype off the diagnostic biopsy. So I think even if you think you’re going to give the patient neoadjuvant chemotherapy, you don’t want to give it to them just because you think you’re going to be able to shrink the tumor. And so I don’t want to just be giving chemotherapy for a 10% chance that the patient will achieve a complete pathologic response. So in the case of nonlocally advanced, ER-positive breast cancer where I’m not so certain what the true benefits of chemotherapy be, ER-positive, I think it’s appropriate to order the Oncotype off the diagnostic biopsy. I’ve been surprised at how frequently it’s successful. I think in the early days, Oncotype, we were worried there wasn’t going to be enough tissue to run the assay on. And that’s just not been my experience, nor, I think, many people’s experience. And once you’ve pulled that trigger to run the Oncotype and made a decision that you would recommend chemotherapy, whether it be in the neoadjuvant or the adjuvant setting, I think that that actually is a very helpful bit of information, as opposed to what maybe I was doing 5 years ago, which was, “Okay. ER-positive, maybe need to shrink the tumor to make the surgeon’s job a little easier. I’m just going to give you chemo on the off chance it shrinks.” I think having that Oncotype information is very helpful. DR LOVE: So just to clarify, though, in terms of what you’re talking about, Kim, in terms of the diagnostic assay, so they do the assay. And then you have the ER and HER2 as well as the fact that it’s a positive biopsy for adenocarcinoma, for example. And at that point you do the Oncotype on the tissue. DR BLACKWELL: Correct. So if I knew I had an ER-positive, HER2/neu-negative — and those are the patients I’m ordering the Oncotype in the adjuvant setting — I frequently will order the Oncotype off the diagnostic biopsy when I’m making a decision about what do I believe the patient will benefit from in terms of chemotherapy? And if I know I’m going to give them chemotherapy, I actually don’t perceive there’s a downside to giving it in the neoadjuvant setting, with the caveat that I don’t set an expectation in ER-positive, HER2/neu-negative breast cancer that neoadjuvant chemotherapy is going to melt your tumor away. I think everyone gets disappointed if you’re giving chemotherapy in that situation. And I think the Oncotype helps a little bit, justify the use of chemotherapy in Stage I/II ER-positive, HER2/neu-negative breast cancer. DR MAMOUNAS: And, I mean, there’s clear data that show that higher Oncotype score results in higher rates of pathologic complete response. So you at least can tell the patient that in the situation of a high Recurrence Score, you’re expected pathologic response rate is higher. It’s not the upper rates of 10% to 15%. DR BLACKWELL: Yes. The net sum here is that you don’t want to give chemotherapy in the neoadjuvant setting to a patient that you wouldn’t give chemotherapy to in the adjuvant setting. DR MAMOUNAS: Right. DR BLACKWELL: And if you are seeing a patient up front and you’re questioning would I give this patient chemotherapy in the adjuvant setting at all and I definitely would order an Oncotype in the adjuvant setting, then I wouldn’t necessarily give them neoadjuvant chemotherapy under the pretense that you’re going to shrink it away. And that’s where I think having the Oncotype along with the ER and the HER2 — HER2 being negative — prior to making the decision about chemotherapy at all, and then you can put in the timing. It is a little complex. |