Multidisciplinary Assessment of HER2+ Breast Cancer

Hope S. Rugo, MD:The treatment of patients like this really requires a multidisciplinary approach, and it’s really the best way to treat patients by far. In our clinic, we’re fortunate enough to have breast oncologists, breast surgeons, radiation oncologists, social workers, nurses, nurse practitioners, and genetic counselors all really housed in the same area, as well as plastic surgeons who are in our clinic a certain number of days a week. So, that means that patients can be seen together by a team when necessary and then not otherwise.

Certainly, medical oncology patients need a lot more visits with their medical oncologists and they need it in a team approach. But when somebody’s first coming in with their cancer and you need to make some decisions about treatment, having that multidisciplinary approach really gives the patients the best sense of what their options are and it also allows us to talk. For example, a surgeon may refer a patient who has a low-gradeER-positive cancer because it’s big for neoadjuvant therapy. And we’ll say, “Well, it’s not going to really shrink from this, so maybe we should think about an alternate route.” For somebody who can’t have radiation therapy, for example, it’s useful to have the radiation therapist there. Maybe they have an autoimmune disease that prevents it or a DNA-damaging inherited mutation. In those patients where you’re going to go for a mastectomy up front, maybe you’d make some different choices.

In this situation with theHER2-positiveER-negative disease, we would all have a consensus that regardless of the type of surgery, we would want to give the treatment up front as much to improve the surgical options as to help us triage therapy both after surgery and in the longer run. And in our institution, because we’ve been very focused on neoadjuvant therapy, patients are referred all the time for neoadjuvant treatment. Anybody with node-positive disease with a tumor that’s over 2 cm is referred routinely. So, this is a particular case where the biology also mandates the referral. And I think in the community, it really depends on where you are, but there’s an increasing sense of the importance of neoadjuvant therapy for patients with this kind of biology tumor. So, I see them referred more and more now than before. And it’s really tragic when a patient like this goes to the operating room first rather than actually having the systemic treatment first.

And then, a lot of times, patients will say to us or their families, or both, “What’s my prognosis now you’ve diagnosed me with a stage 2B tumor?”—and clinical stage 2B. There could be more cancer if you did surgery up front. And I say, “Look, the proof is in the pudding here. We don’t know what your prognosis is today. We’re going to know much better after we see how you respond to treatment. Because the chances of you having a recurrence, regardless of the stage that you’re starting at, will drop down dramatically if you have an excellent response to neoadjuvant therapy. Whereas you may still have some residual risk, which is important to us in terms of thinking about subsequent therapy if you don’t have a pathologic complete response or at least close to it.”

Transcript edited for clarity.

• A 53-year-old woman was referred to a breast surgeon after finding a mass in her left breast
  • PMH: unremarkable
  • FH: no history of cancer in first-degree relatives
  • PE: revealed a 6 X 5-cm, non-fixed mass in the left inferior breast without skin changes or nipple discharge, and palpable lymphadenopathy in the left axilla
  • ROS: clear
• Mammogram confirmed a left-sided, poorly defined spiculated mass. Ultrasound shows a 5.3-cm solid mass and enlargement of 2 left axillary nodes with thickened cortex
• Pathology results:
  • Core needle biopsy from the breast mass confirmed grade 3 invasive ductal carcinoma
    • ER—,PR—,HER2IHC 3+
    • FISH,HER2copy number, 15;HER2:CEP17 ratio, 7
  • Fine-needle aspiration of one left axillary lymph nodes was positive for carcinoma
• Staging: T2bN1M0