Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A 47-year-old premenopausal woman with Stage IIB (T2N1M0) ER/PR-positive, HER2-negative IDC and a 21-gene RS of 13 elects to receive endocrine therapy alone
4:48 minutes.
TRANSCRIPTION:
DR SPARANO: This was a 47-year-old premenopausal black female who presented with Stage IIB ductal carcinoma of the left breast, had a wide excision and a sentinel lymph node biopsy with 1 of 3 positive sentinel nodes, with a 5-mm macrometastasis. The primary tumor was 2.1 centimeters. It was of intermediate grade. It was strongly ER/PR-positive but HER2-negative. Based on her young age, the fact that she had a T2 lesion and node-positive disease, I recommended adjuvant chemotherapy. We ordered an Oncotype DX Recurrence Score, and it was low, 13. We discussed the options and also reiterated the fact that chemo/endocrine therapy was still a recommended standard of care in her case but that she might be someone who may not derive as much benefit from chemotherapy as we would normally expect or hope. And after discussing the options, this patient elected to receive endocrine therapy and, of course, radiation therapy, but deferred chemotherapy. DR LOVE: I’m curious if you can talk a little bit about this woman herself and what she was thinking, what kind of background she had, what her thoughts were about chemotherapy. DR SPARANO: I think, like many young women, she is someone who would like to avoid chemotherapy, if possible, and the potential side effects, both short term and long term, of adjuvant chemotherapy, but was willing to endure it and receive it if she knew that it was going to be beneficial and that there was a good chance of it being beneficial. She also understood that the stakes were high, that chemotherapy prevents a recurrence and that a recurrence in distant organs is a catastrophic event — that the disease is treatable in that situation, but it’s not curable. So I could tell you that I’ve seen other patients in this circumstance with the same information who’ve elected to receive chemotherapy. So it’s a very individual decision. We will have, I think, a much firmer database, evidence based, upon which to make recommendations once we have the results from the TAILORx trial, once we have the results from the RxPONDER trial in particular, for this particular situation. DR LOVE: Now, she did not have an axillary node dissection, correct? DR SPARANO: Correct. DR LOVE: So she’s like a typical ACOSOG Z11 situation. Do you think if you knew she had, let’s say, 4 positive nodes, you would have thought it through differently, or she would have? DR SPARANO: Regarding the chemotherapy decision, for sure, yes. And I may not have actually ordered an Oncotype in that circumstance, because I think the overwhelming evidence would have suggested that this is someone who definitely needs chemotherapy to reduce their risk of recurrence. And I’m not sure I would have ordered an Oncotype on this patient, say, 10 years ago when we were just beginning to order the test and we had the information based on other studies, 8814 study, for example. So I think that this case does exemplify how things have changed over the last decade and how, because of our decade-long experience about using this assay and other assays to provide prognostic information in situations, mainly in node-negative disease, we’ve gotten a greater comfort level with using the assay in women who are at higher risk of disease based on anatomy — that is, the extent of nodal involvement. DR LOVE: So I know there are algorithms to try to predict whether or not there would be more nodes positive. What would be your estimate in terms of the likelihood that she really has a total of 4 nodes positive? DR SPARANO: One would need to know specific details and plug that information into the algorithm. And we went through that exercise in this particular patient. And her risk was low. In addition, we knew that she was going to be getting radiation therapy. So for that reason, we elected not to do the completion axillary dissection. |