Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Use of the 21-gene RS to guide neoadjuvant therapy decision-making
2:41 minutes.
TRANSCRIPTION:
DR LOVE: There was 1 other thing we saw in the survey that I thought was very fascinating, which is the question of management of the patient with ER-positive, HER2-negative tumors where neoadjuvant therapy is a consideration. And we know that globally those patients don’t seem to respond as well to chemotherapy. What we saw in the survey was that either the oncologists or surgeons favored just sending the patient to surgery and skipping neoadjuvant therapy or, interestingly, about a third of the investigators are actually using genomic assays to help make the decision, mainly the 21-gene Recurrence Score, the thinking being that, even though we don’t have that much data, we know the same tumor postop, we’re going to do that test and it’s going to help us decide about chemo. What about at Dana-Farber and in your own practice? Do you ever consider genomic assays in a patient with an ER-positive, HER2-negative tumor, where you’re thinking about neoadjuvant therapy, maybe even considering neoadjuvant hormonal therapy? DR KING: Yes. And that’s a very good point. And we struggle with these cases, certainly, particularly in the patients that would benefit from some downstaging. It’s important, I think, to remember when we say ER-positive tumors don’t respond as well, really what we’re saying is that they don’t have as high of pathologic complete response rates. And to optimize a woman’s opportunity for breast conservation, we don’t need a path CR. We just need some shrinkage in the majority of cases. And so I think we again have to be careful. What is our goal? What are we going for here? We do use neoadjuvant endocrine therapy in some patients. We were doing it on trial in the ALTERNATE study. We also have a preop trial here for invasive lobular cancers, ER-positive, with neoadjuvant endocrine therapy. And so we have, again, do it on study. And I have had some patients where we’ve used preop endocrine therapy off study too, in selected patients who were motivated. We know that you have to stay on the endocrine therapy for an extended period of time, typically the 4- to 6-month window, to really see that optimal response. But for some patients, that is an attractive option. Using the genomic test is also very interesting. I know there’s at least 1 publication in the literature supporting the use of Oncotype 21-gene Recurrence Score to identify those women that would benefit from preoperative chemotherapy in the setting of ER-positive disease. I have not had a particular case where we’ve done that, but I certainly understand the rationale, if you’re struggling with that decision up front and have something to gain from giving preop therapy. |