Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Effect of ER and HER2 status on the use of neoadjuvant chemotherapy
4:00 minutes.
TRANSCRIPTION:
DR LOVE: As you know, because you participated in a survey that we did of 61 investigators, half surgeons, half oncologists, we actually presented that as a poster at San Antonio. DR LOVE: Now, this patient had a particular reason to get neoadjuvant therapy, in that she wanted breast conservation and really would have done better with tumor shrinkage. But for the more typical patient where that’s not an issue, one of the things that we saw in this survey that was very interesting was that both in patients who are triple-negative as well as HER2-positive, very proactive about using neoadjuvant therapy, both the oncologists and the surgeons, as opposed to, for example, ER-positive, HER2-negative disease. And what we actually saw was that a majority of the investigators — again, for HER2-positive or triple-negative — would prefer seeing the patient get neoadjuvant therapy even if the axilla was completely negative, the tumor was 2 centimeters or greater. Again, do you buy into this ER/HER2-based algorithm and this proactivity about neoadjuvant therapy? DR KING: I actually do. And I think that it’s really exciting for patients, because I think, from a surgical point of view, what’s driving our enthusiasm is the opportunity to avoid the axillary node dissection and the subsequent morbidity for our patients. So we know, even if women are clinically node-negative, depending on the tumor size, there’s still a real chance that we’ll find microscopic disease if we went to surgery, primarily. And so just having the increased rates of pathologic complete response that we’re seeing, we know the rates of pCR are actually higher in the nodes than they are in the breast. We’ve seen reports of them being as high as 90% with HER2-positive therapy. Certainly with triple-negative disease, they’re at least 50%. And so I really do think that it’s an important conversation to have, because if we can sterilize that nodal base and we really spare our patients one of the things that they’re most concerned about, which is that risk of lymphedema. DR LOVE: And it’s interesting, too, people originally, I think, when they thought about neoadjuvant therapy, were hoping — Bernie Fisher, et cetera — that it would affect long-term distant recurrence, which it doesn’t seem to do. And it’s kind of ironic now that it’s come full circle, that there’s a lot of proactivity. But it’s really about reducing local therapy — as you say, the axilla. I’ve also heard people say, even if they’re doing a mastectomy, they’d rather have the tumor shrunk down first in terms of ease of surgery, margins, et cetera. Again, do you buy into that? DR KING: Sure. There are times when even if you’re doing a mastectomy, if the tumor’s particularly close to the pectoralis muscle or particularly close to the skin, there’s nothing to lose by shrinking that tumor down, even if you’re still going to do a mastectomy. Also, today we see a lot of women who are choosing to have mastectomies for personal reasons. So we might tell them they’re perfectly good candidates for breast-conservation therapy, but yet they still choose to have a mastectomy. And so we are not seeing rates of breast conservation increase to the extent that we’re seeing, again, rates of path CR increase in the breast, right? So we have all these new neoadjuvant trials, particularly in the HER2-positive setting, where we’re seeing path CR rates of 50%, 60%, but yet if you look at rates of conservation in those studies, they are no better than they were in the older, preop ACT studies. So we certainly haven’t capitalized on neoadjuvant therapy for breast preservation as much as maybe we thought we would before. And again, that’s a complicated decision-making process between the patient and her physician, whether she wants to choose to save her breast. But the new just appreciation of how we can do less in the axilla, again, I think it’s a very important factor, because every woman wants to avoid that risk. |