Cases from the Community: Investigators Provide Their Perspectives on the Practice Implications of Emerging Clinical Research — A Special Video SupplementCase discussion: A 58-year-old woman with ER/PR-positive, HER2-negative invasive lobular carcinoma
3:17 minutes.
TRANSCRIPTION:
DR LOVE: So here’s another case, really interesting situation: Fifty-eight-year-old postmenopausal woman who has a 5-cm, ER/PR-positive, HER2-negative, invasive lobular cancer. And the surgeon has sent the patient to the medical oncologist asking whether it could be shrunk down. I would imagine this relates to breast-conserving surgery. So the question is hormonal therapy versus chemotherapy and genomic assay. DR O’SHAUGHNESSY: That’s hard. Lobulars are difficult, because they are oftentimes far larger than you can appreciate on any imaging modality. And the fact that this one is already 5 cm, that people can appreciate, makes me worry that this woman may not at all be a great breast-conserving surgery candidate. So I’m not terribly enthusiastic about that. However, sometimes it’s necessary to give women more time to think through what’s going on with this whole breast cancer situation before they have to make their final decision about what kind of surgery that they want. So I would not be averse to treating this patient preoperatively. If somebody said, “Is there an advantage to me,” if the woman were neutral in her opinion of mastectomy versus lumpectomy/radiation, if she we neutral I would lean her toward a mastectomy. And I would tell her there would be no advantage to her to getting preoperative therapy. But if women need more time to think through genetic testing or what they want to do with surgery, then there’s nothing the matter with doing preoperative. In terms of a Recurrence Score, I don’t really feel we have, necessarily, enough data to say that, “Gee, if it comes back with a low Recurrence Score, we could just go with endocrine therapy alone for this situation.” So in a 5-cm, 58-year-old woman, I would be leaning toward chemotherapy for her. DR LOVE: Could I just ask, if you knew she had a Recurrence Score that was 5, would you still give the chemo? DR O’SHAUGHNESSY: It is something we think about, Neil. And another question is, what if she had a mastectomy and she had 5 cm and, hey, it was node-negative or 1 node positive, and the Ki-67 was 5%? What are you going to do? And so there are situations, Neil. This is not a one-size-fits-all. There definitely are situations where you look at this and you say, “Wow! We can’t be waiting too long to get the endocrine therapy going on this patient if we really expect to get her some good cytoreduction.” And so if somebody came in with a low Recurrence Score in this situation, I’d look at the other biologic features. If they’re strongly ER/PR-positive, low Ki-67, more of a classical lobular as opposed to a pleomorphic lobular and she’s 58 years old, I would probably put that on the table for her, Neil, just starting with letrozole and then seeing how she did and seeing what the residual disease was and then going from there with the Ki-67. We do that. We’re individualizing. We’re bringing that biology in more and more. |