Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A 42-year-old woman with strongly ER/PR-positive, HER2-negative, node-negative multifocal infiltrating ductal carcinoma (IDC) and a 21-gene RS of 19
7:11 minutes.
TRANSCRIPTION:
DR KING: I recently saw a 42-year-old who was diagnosed with a right-sided invasive breast cancer. She preoperatively was known to have one foci of disease in the breast, which we knew was intermediate grade and ER-positive. And she elected to undergo a mastectomy and sentinel lymph node biopsy. On the final pathology, she actually had multifocal disease. She had the known 1-cm tumor, as well as a 0.9-cm tumor. Both of them were moderately differentiated. There was no lymphovascular invasion. The margins were all clear. Obviously, we performed a mastectomy. And both were strongly ER- and PR-positive and HER2-negative. So she was a pathologic Stage T1b multifocal disease. And her 3 sentinel lymph nodes were negative. So she was evaluated by one of my colleagues in medical oncology regarding her decisions for adjuvant therapy. And an Oncotype DX® test was ordered, and it returned with a Recurrence Score of 19. DR LOVE: So at that point, what was the discussion that was had with the patient, I guess primarily with the oncologist, but in terms of chemotherapy? She has a low Recurrence Score. Maybe not as low as, for example, as reported in the big study, but still considered low. So how did that translate into the decision? DR KING: So the Recurrence Score of 19 is really right there at the borderline between low and intermediate. And so I imagine that if she would have gotten several opinions from oncologists, she probably would have received different recommendations. There are some who are comfortable with the low score cutoff of 18. There are others who prefer to use the cutoff of 11, as was used in the TAILORx trial. But the original development and the validation of the score obviously was used with the cutoff of 18 for a low score. Here at my current institution, the oncologist that she met with was comfortable treating her with adjuvant hormonal therapy, did not feel like there was a large benefit to be gained from using adjuvant chemotherapy. DR LOVE: Now, just to clarify, she had 2 primary tumors? DR KING: She did have multifocal disease, yes. DR LOVE: And was the Oncotype done on both areas? DR KING: So the Oncotype was just done on the largest of two, which in this case, one, again, was 1 centimeter, and one was 0.9. They were morphologically similar. They were both intermediate grade and both, again, strongly ER/PR-positive and HER2-negative. So one would predict that they would have concordant Oncotype scores. But that’s certainly a good point when you are looking at women who have multifocal disease if you are concerned that the biology of the two tumors may be different. DR LOVE: I see you had a paper in the Annals of Surgical Oncology not that long ago, earlier this year, not a journal I usually read. But I found it when I saw your resume. But I was really interested when I saw it, Oncotype DX in Bilateral Synchronous Primary Invasive Breast Cancer. What did you see there? DR KING: So we found that in the majority of the time, if a woman presents with concordance between ER, PR and HER2 that there will also be concordance with her Oncotype grouping as far as low, intermediate or high risk. But there certainly were a number of cases, I believe maybe on the order of 10% to 15%, where performing the Oncotype on the contralateral tumor did, in fact, change treatment recommendations for the patient. So again, I think you have to take everything into consideration, the morphology of the tumor, the ER/PR/HER2 status. The size obviously comes into play when we’re making some decisions. But typically the pathologists will send the tumor that they would expect to have the worse biology, if we can use the word “worse.” They’ll typically pick the one that they expect to have the higher score. And if they are very similar and it’s unclear which one to pick, sometimes there can be consideration for sending both. DR LOVE: Interesting. What was this lady’s attitude about chemotherapy? And was she comfortable not receiving it? DR KING: She was, yes, very comfortable not receiving it. She is actually a healthcare worker herself. And she really strongly desired avoiding chemotherapy, if, in fact, there wasn’t going to be a significant benefit. So she was very comfortable with the recommendation for hormone therapy. DR LOVE: So you’ve now migrated from Memorial up to Dana-Farber, 2 places where we talk a lot with the medical oncologists in terms of breast cancer, and particularly at Dana-Farber, very pro using genomic assays, Hal Burstein, Eric Winer, et cetera. Right now, I’m curious how genomic testing kind of fits in with the oncologists at the Dana-Farber, as opposed to where you just came from, which is Memorial. And one of the questions that comes up a lot, there’s a lot of debate on, is the issue of the patient with node positivity, 1 to 3 positive nodes. DR KING: Yes. It’s a very timely topic. So when I first moved to Dana-Farber about a year ago, at Memorial we were not sending Oncotype on women with node-positive disease. I’m honestly not clear whether they are sending it routinely now. I’m sure that they’re using it in certain scenarios. But here at Dana-Farber, the oncologists are quite comfortable sending Oncotype in women with 1 to 3 positive nodes. And we have set some predefined criteria here so that, again, the surgeons can go ahead and order the test without waiting for the patient to see the medical oncologist, to eliminate that delay time in being able to make those treatment decisions. So we do order it, again, in women who have node-positive disease with 1 to 3 positive nodes, if we think that there is an opportunity to assist in the decision-making. DR LOVE: What about in node-negative patients? Is that pretty much a routine? Again, issues have come up, for example, at the extremes of age: very young patients, very older patients. In general, are you sending off a 21-gene Recurrence Score if they’re node-negative? DR KING: In general, yes. But we do have some size criteria, and we also account for tumor grade. So we do not send it in Grade 1 tumors. And there are some Grade 2s where, based on size, we may not send it. So we have some criteria. If it’s a T1b Grade 3, we’ll send it. If it’s a T1b Grade 2, we may not routinely send it. But we have these discussions back and forth with our oncologists to determine who they’d like to have the results for. |