Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A 52-year-old postmenopausal woman with ER/PR-positive, HER2-negative, node-negative IDC and an RS of 12 undergoes breast-conserving surgery (BCS)
5:00 minutes.
TRANSCRIPTION:
DR KHAN: This is a 52-year-old postmenopausal woman. She had a prior history of LCIS. I actually saw her at that time and recommended that she consider tamoxifen therapy, but she didn’t want to do that. And she came back then with a palpable 3-cm mass in the upper-outer right breast. She didn’t have any clinical axillary adenopathy at the time. And she had no other lesions on conventional imaging. We don’t routinely use MRI for these patients. She opted to proceed with breast conservation. She had no family history of breast cancer or other cancers. And the features of her cancer included, on core biopsy, Grade I invasive ductal histology. She had positive hormone receptors rich in ER and PR, a low Ki-67 and negative HER2. So we performed breast-conserving surgery for her, which went fine. Her margins were free, and her lymph nodes were negative. She had 2 or 3 negative sentinel nodes. So at that point, I think in the pregenomic evaluation era with a 3-cm mass, she would have been offered chemotherapy as an option to consider fairly strongly. But we submitted her tumor for the 21-gene Recurrence Score and she had a Recurrence Score of 12. Which translates into a 10-year disease-free interval of 93% or better. So she clearly had a low-risk tumor based on biology. And given the validation of the 21-gene Recurrence Score that we’ve seen through the years, we felt very comfortable in advising her not to have chemotherapy, and she was treated with endocrine therapy alone. So she was started on anastrozole. DR LOVE: So I assume — did she see a medical oncologist? DR KHAN: She did, yes. Absolutely. So these cases are discussed in a multidisciplinary setting. DR LOVE: And at what point did you decide to send for the 21-gene Recurrence Score? After you knew her nodal status? DR KHAN: Correct. Yes. DR LOVE: And if it turned out that she had a positive node, would you have still sent a genomic assay? DR KHAN: So until recently, we were recruiting to the SWOG study that just closed, the RxPONDER study. And that 1 to 3 positive axillary nodes are the group that are eligible for genomic evaluation and randomization. So this is, again, specifically for the 21-gene score, not any of the other assays. So now that study is closed, so it’s a question of deciding off study, but because that study was conducted and the data behind the study, we do discuss the possibility of sending a score on someone who could be considered for therapy without chemotherapy. DR LOVE: Now when you make this decision to send off a test like this, I would assume you’re talking to the patient also about, I guess, what, her thoughts about chemotherapy? Do you actually discuss that with the patient or you just routinely send it? DR KHAN: No. We do discuss with the patient. And again, particularly for these cases, for the 1 to 3 node group where this is not standard of care at the moment, it’s still somewhat an investigational technique. We do discuss it at our conference. I never send a score without either a telephone conversation or a conference discussion with a medical oncology colleague. Because it would be a waste to do a score when that information would not be considered valuable by medical oncology. DR LOVE: What was your sense about this lady in terms of chemotherapy? Do you think that she was willing to receive it but she just wanted to make sure that there was adequate benefit? Or any personal experiences? DR KHAN: Right. So I think this particular lady would have been happy to proceed with chemotherapy if she were advised to do so and if it was clear that it would reduce her risk of recurrence. But given the information from the 21-gene score, I think one can say with confidence, particularly given the recent early results from the TAILORx trial, that with a low score, her benefit from chemotherapy would be very slim, if any, and her prognosis on the whole is very good and so endocrine therapy alone would be perfectly adequate. And she was happy with that recommendation. |