Medical Oncology Considerations: Neoadjuvant Therapy for Treatment - - PowerPoint PPT Presentation

Medical Oncology Considerations: Neoadjuvant Therapy for Treatment

• f Breast Cancer

Nancy U. Lin, MD Breast Cancer Mock Tumor Board NNECOS Meeting 2016

Question 1

Neoadjuvant therapy leads to:

• a. Improved RFS and OS compared to adjuvant

therapy

• b. Improved chance for breast conservation
• c. Worse cosmetic result compared to upfront

surgery

• d. Reduced risk of systemic relapse compared to

adjuvant therapy

• e. None of the above

Question 2

Reasonable options for this patient could include:

• a. TCHP (docetaxel, carbo, trastuzumab, pertuzumab) followed by surgery

then H to complete 1 year

• b. THP (trastuzumab, pertuzumab, weekly paclitaxel) followed surgery, AC x 4,

then H to complete 1 year

• c. Upfront surgery followed by AC (doxorubicin, cyclophosphamide) 

THP (paclitaxel, trastuzumab, pertuzumab) and maintenance HP to complete 1 year

• d. A and B
• e. All of the above

Question 3

For patients with ER/PR negative breast cancer, the use

• f ovarian suppression just prior to and during

adjuvant chemotherapy has been shown to:

• a. Reduce rates of ovarian failure at 2 yrs from

chemotherapy and improved pregnancy rates

• b. Reduce rates of ovarian failures at 2 years but no effect
• n pregnancy rates
• c. No effect on either menstrual function or fertility

Reasons to Consider Neoadjuvant Therapy

Local

• Improved chance of BCT
• Reduced surgical

morbidity

• Convert to operable

candidate (e.g. IBC)

• Allow time for genetic

testing that may impact choice of surgery Systemic

• Some FDA indications

limited to neoadjuvant setting

• Clinical trial
• Prognostic information
• ?Tailoring of treatment

– E.g. preop endocrine – E.g. post op CREATE‐X

Reasons to consider Initial Surgery

• Able to have upfront BCT
• Mastectomy required regardless of preop response

(e.g. extensive calcs; multicentric disease)

• Indication for adjuvant chemotherapy or extent of

adjuvant chemotherapy unclear

– ER+/HER2‐ and clinically node negative 1 – HER2+ clinical stage I2

• Desire for embryo/ooctye harvesting

1. Paik et al, NEJM 2004; Sparano et al NEJM 2015 2. Tolaney et al, NEJM 2015

Role for Genetic Testing

• Informative for many reasons

– Type of breast surgery (BCT vs mastectomy) – Trial eligibility (e.g. OlympiA, NCT00494234) – Future breast screening (indication for MRI) – Other risk reduction (oophorectomy, other screening) – Family counseling

Fertility Considerations

• G2P2 – discuss couple’s desire for more children and refer to fertility expert for

discussion of options if interested

• Pregnancy

– Likely not to directly increase recurrence risk – But, implications if ER+ patients stop hormonal therapy early (POSITIVE study prospectively evaluating this)

• Embryo/oocyte harvesting

– Timing vs need for neoadjuvant tx

• Role for goserelin

– Moore et al, NEJM 2015 – OS started 1 week prior to 1st chemo and continued to within 2 weeks before or after the final chemo dose –

• varian failure rate 8% vs 22% (p=0.04); pregnancy in 21% vs 11% (p=0.03); no decrement in

DFS or OS (in fact slight improvement was observed)