Medical Oncology Considerations: Neoadjuvant Therapy for Treatment of 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 of 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 on pregnancy rates c. No effect on either menstrual function or fertility
Reasons to Consider Neoadjuvant Therapy Local Systemic • Improved chance of BCT • Some FDA indications limited to neoadjuvant • Reduced surgical setting morbidity • Clinical trial • Convert to operable • Prognostic information candidate (e.g. IBC) • Allow time for genetic • ?Tailoring of treatment testing that may impact – E.g. preop endocrine choice of surgery – 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 I 2 • 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 1 st chemo and continued to within 2 weeks before or after the final – chemo dose – ovarian 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)
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