Consideration for Neoadjuvant Treatment in HER2+ Ductal Carcinoma

Ruth O’Regan, MD:This is a 58-year-old lady who is known to have a mass in her right breast by her gynecologist. She was then sent for imaging and to see a surgeon. The ultrasound basically confirmed this 3 cm mass in the breast and also noted a possible suspicious lymph node in the axilla. She had a biopsy of both the breast mass and the lymph node, and it revealed invasive ductal cancer—estrogen receptor—negative, progesterone receptor–negative, and HER2-positive. So, the surgeon had her case discussed at the tumor board and it was recommended that she get referred for a preoperative treatment, which is essentially what was done.

This is a reasonably common case we see. In general, for patients who have cancers that are HER2-positive that certainly are more than 2 cm, particularly when they’re a positive lymph node, they are very good candidates for preoperative approach. I think the majority of us would consider using some type of preoperative chemotherapy plus HER2-directed therapy in a patient like this to try and downstage the cancer, but also because we know that response, in these HER2-positive cancers, particularly when they’re hormone receptor—negative, is very high and is associated with very favorable prognosis for patients if you can get a complete response.

I think surgeons increasingly are referring patients to medical oncology when they’ve got HER2-positive cancers that are larger, and are node positive. So, a patient like this who had a larger cancer and a positive lymph node, I think most times they would get referred to medical oncology, initially. It’s probably a little bit more common in academic centers, but I think it’s becoming more universally used. You certainly could do surgery up front, but preoperative approach definitely offers some advantages, and I think it would be very appropriate to send this patient over to medical oncology. In our center, pretty much every one of our surgeons would refer a patient like this for chemotherapy and HER2—directed therapy, unless they were much older. This is a relatively young woman, but if they were in their 80s, they may not do it. But, I think, in general, we’re increasingly doing this more and more.

For a patient like this with a T2 cancer that’s got a positive node and is HER2-positive, and hormone receptor-negative, I think referring the patient to medical oncology is highly appropriate because it offers the chance of downstaging the cancer. Also, we can see what the systemic therapy is going to do in terms of whether the cancer is responding or not. And, additionally, we know that if we can achieve a complete response, which is reasonably light in a cancer like this with this type of treatment, the patient will have a very favorable prognosis. So, I would definitely agree with the surgeon for sending a patient like this over to medical oncology. I think that’s the right approach for the patient.

Case Scenario 1:

• This is a post-menopausal 58-year-old female in whom a mass was discovered in her right breast during her annual mammography.
• Her gynecologist referred her to a breast surgeon; results of her biopsy revealed 3 cm ductal carcinoma
• Pathology shows: ER— & PR–, HER2 IHC 3+
• Clinical staging; T2aN1M0
• Her surgeon discussed the patient’s case at the Breast Tumor Board and it was suggested that the patient be referred to a medical oncologist for consideration of HER2-targeted neoadjuvant therapy.
• The surgeon shared his opinion with the patient who agreed to go to the medical oncologist to discuss her options.