HR+ Breast Cancer: Prognostic Indicators
Criteria used by breast oncologists to risk stratify patients who present with HR-positive breast cancer.
Kevin Kalinsky, MD, MS: For this particular patient, if we find that there’s 1 independent factor for risk, it’s the presence or absence of lymph nodes.
This patient has no positive disease. Ki67 is a marker for tumor proliferation. Anything greater than 14% is considered quote-unquote, high, but clearly, we see Ki67s that are 80% to 90%, and those are more proliferative tumors compared to somebody who’s just 30%. Size is important.
I think also genomics. So, we talked about the 21-gene [recurrence] assay. We have data from the RxPONDER trial that patients who are postmenopausal have a recurrence score that’s less than 26 with 1 to 3 positive nodes don’t benefit from the addition of chemotherapy. So it’s an important prognostic indicator. This particular patient had a recurrence score that was 30, grade 3 tumor, Ki67 30%. All of those factors would lead me to discuss doing chemotherapy with her.
And her tumor was strongly ER-positive, PR-positive as well. So she’ll benefit from doing endocrine therapy and she would be a candidate for 2 years of abemaciclib [Verzenio] as a result of the monarchE study.
Because she had a high recurrence score and some of the other factors that I mentioned that can be concerning like the grade and the Ki67, all those factors lead somebody to think about, maybe this isn’t the kind of tumor that’s just going to be endocrine sensitive.
And they would benefit from doing chemotherapy and our recurrence 30 and would have been entirely appropriate to give this patient chemotherapy. Commonly, we do the chemotherapy first then followed by the endocrine therapy.
There are options like aromatase inhibitors or tamoxifen. For this patient, I would start out with an aromatase inhibitor because we know that the relative and absolute risk for this patient is high enough that there would be a difference in terms of preferential use of an aromatase inhibitor.
We would think about abemaciclib for this patient because she would have been eligible for the monarchE study. The other thing just to mention is that for somebody who’s premenopausal.
So if I saw this patient and she was 40 years old with this recurrent scoring, 2 nodes involved, etc., I would talk with this patient about doing ovarian function suppression.
As we know from data like the SOFT TEXT trial that they seem to benefit even more than a decade out from that sort of approach. So this particular patient was premenopausal.
The other thing I would think about adding would be a GnRH [gonadotropin-releasing hormone] or undergoing some sort of procedure like oophorectomy to induce menopause because she would have an absolute benefit with doing that.
Transcript edited for clarity.
Case: A 67-Year-Old Woman with ER+/PR+ Breast Cancer
Initial Presentation
- A 67-year-old, postmenopausal woman presents with a newly diagnosed lump in her left breast
- She has 2 grown children, no family history of cancer, and underwent menopause at age 48
- PMH is significant for hypertension that is well controlled with medication
Clinical work-up
- Imaging demonstrated a 4.4-cm solid mass in the right upper quadrant with no suspicious adenopathy
- Core biopsy: positive for invasive ductal carcinoma, ER 100%/PR 40%; HER2 IHC 1+; Ki-67 30%; modified Bloom-Richardson grade 3
- Lumpectomy and sentinel lymph node biopsy performed
- Tumor size is 4.5 cm, and 2/5 LNs are positive for metastatic disease
- 21-gene recurrence assay score is 30
- T2N1M0, stage IIA
- ECOG PS is 0
Treatment
- Patient underwent partial mastectomy with no residual disease
- She is started on adjuvant chemotherapy with cyclophosphamide and docetaxel
- She is given radiation therapy to intact breast
- Followed by aromatase inhibitor + 2 years of abemaciclib
