Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A 37-year-old woman with a 3.5-cm ER/PR-low, HER2-positive, clinically node-negative BC
4:53 minutes.
TRANSCRIPTION:
DR GRADISHAR: This is, again, a lady that I saw yesterday, who is young, 37 years old. She presented with a T2 lesion. It was about three and a half centimeters by imaging, somewhere in that vicinity by clinical exam. She was potentially operable just as is, right from the get-go. A biopsy was done. She was HER2-positive, ER/PR-poor but not negative. And as I said, the decision could have been made — of course, this kind of patient could get a mastectomy right from the beginning. She was probably on the cusp of operability from a cosmetic standpoint. But because she met the criteria for where we consider using preoperative therapy, meaning a T2 lesion with HER2-positive disease, we did indeed treat her with TCHP. And that’s the current treatment that she’s receiving. DR LOVE: Where exactly is she in the treatment, and how is she doing? DR GRADISHAR: She’s about halfway through the chemotherapy. She’s tolerating it well. There’s an obvious clinical response that we can detect at this point. So the tumor itself is less palpable than it had been. And a not insignificant fraction of these patients will have a pCR at the time of surgery. So I think that this is the perfect example of somebody where we would strongly consider giving preoperative HER2-directed therapy and, importantly, with dual HER2-targeted therapy. DR LOVE: As you mentioned, these patients now are getting both pertuzumab/trastuzumab as well as chemotherapy. And you were mentioning the fact that she’s doing well. When you do see problems or complications, what kinds of things do you see? DR GRADISHAR: The most common things are actually related to the chemotherapy itself rather than the HER2-directed therapy, so the predictable things, the hair loss, the blood count drops, maybe some paresthesias. But with respect to the HER2-directed therapy, that’s fairly minimal. Some patients will complain of loose stools or a little bit more frequent loose stools, not frank diarrhea constantly, but there’s probably a little bit of an uptick in terms of GI symptoms, but that aside, it’s very well tolerated. DR LOVE: So as you mentioned, these patients often will have a complete pathologic response. But I’m curious what you do in this situation where there is residual disease, both in terms of how you approach it outside a clinical trial and whether there are any clinical trials you try to get them in. DR GRADISHAR: So for this kind of patient who — not everybody gets a pathologic complete response — we have to always keep in mind that they’re going to continue on trastuzumab for the completion of a year. And in somebody that’s also ER-poor but not negative, they’re going to get endocrine therapy. So this kind of example, I probably, as a routine, wouldn’t add anything additional to that recipe of drugs. Perhaps if the patient was triple-negative and had residual disease after giving whatever you felt to be optimal preop therapy, there are some considerations, including data not yet published on the CREATE-X trial that was largely conducted in patients from Asia, where, for those who had residual disease, they were treated with capecitabine with some sort of intriguing positive results in those that were triple-negative. And there’s a large cooperative group trial now being done where there isn’t, actually, surprisingly, any control arm. Patients are either getting platinum or capecitabine. And we don’t have any data from that, but that’s a trial we would pitch in that population that was triple-negative with residual disease. DR LOVE: Interesting. And you mentioned the data in the triple-negative patients. Are you using capecitabine now outside a clinical trial setting? DR GRADISHAR: Not routinely. And I think largely the reason that I don’t is the data that gets everybody enthusiastic about it hasn’t been published. So with the exception of hearing it once, I think it’s important to look over how that trial was conducted. It’s a very different patient population. And we know that pharmacogenomics, et cetera, may differ across populations. And we haven’t historically thought of capecitabine, necessarily, as being the best drug for triple-negative disease. So I think it’s important to look over the data carefully before we adopt that as a routine. And, for instance, it’s of course not in the guidelines at this point, because there’s no published data. |