NCI-CCC Breast Tumor Board Question   

Patient underwent an axillary dissection with ITCs in 1/23 nodes.

Would clinical stage or nodal status affect your decision?

As immune checkpoint inhibitors have expanded into the neoadjuvant breast cancer setting, severe and unexpected autoimmune toxicities may cause delays...

For a patient with high risk disease and a severe enough reaction that additional taxane-based therapy is contraindicated, do you consider alternate c...

Do you feel differently about using these in patients with a history of HR-negative breast cancer?

RIGHT Choice trial presented at SABCS 2022

Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...

What type of adjuvant chemotherapy would you offer? Would clinically positive lymph nodes or residual disease at the time of surgery change your decis...

Patient is pre-menopausal and has cT3cN1, grade 2, ER positive, Her 2 negative IDC. Metastatic disease to axillary LNs was biopsy-proven. Patient was ...

With the recent announcement that the phase 3 MonarchE trial met its primary endpoint. 

Had mastectomy resulting in ypT1cN1a. Post menopausal female with good PS. 

If so, under what circumstances?

Does your approach differ across the HER2 IHC spectrum?

MonarchE trial criteria includes "patients with four or more positive nodes, or one to three nodes and either tumor size ≥ 5 cm, histologic grade 3...

Fertility preservation already complete with embryo cryopreservation

Patient is young. Bilirubin normalizes when tucatinib is held, but again increases to grade 2 when it is restarted. Evaluation for hemolysis was negat...

Patient is a post-menopausal woman with 4 lymph node mets that was strongly ER+/PR+, HER2-negative invasive ductal carcinoma with a high Ki-67 w...

At initial diagnosis she had T1cN0 disease treated with lumpectomy and SLNB followed by 12 weeks of paclitaxel with 1 year of trastuzumab.

Would you consider definitive local therapy (surgery, radiation?) if she achieved a good response to initial systemic therapy?

Young patient, germline BRCA carrier with cT1cN0 to ypT2N0 disease after docetaxel/ cyclophosphamide x 4.

Which agents would you select and for how long would you treat them?

Patient is young and reoccurrence is one year after initial diagnosis of T1cN0 ER/PR positive, HER2-negative breast cancer treated with mastectomy, bu...

Patient underwent mastectomy for DCIS in the setting of previous lumpectomy and adjuvant radiation for the invasive breast cancer. 

Patient is ypT2N1

Patient has already received neo/adjuvant treatment with AC, paclitaxel, capecitabine, docetaxel, and carboplatin.

Would you consider neoadjuvant or adjuvant treatment and if so, which therapies? Patient initially had pT2N0 disease and recurrent disease is also ER+...

Patient previously received neoadjuvant ddAC-T with residual disease at surgery, followed by adjuvant capecitabine which was completed 2 months prior ...

High-risk criteria meaning >4 positive nodes and Ki67 >20%

This situation can feel uncomfortable.  Would this feel safer if patient is s/p mastectomy and had TNBC?

Largest invasive focus is 0.4mm

CNS recurrence occurred within two years of prior neoadjuvant therapy

Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?

ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.

Patient was on tamoxifen when progression occurred; unable to tolerate adjuvant AI.

How would this affect adjuvant radiation plan in breast conservation therapy patients and mastectomy patients?

Do you have a specific age cutoff?

Patient with T2N1 disease and isolated liver metastases. Axilla and liver completely responded to chemo + IO, but limited residual breast enhancement ...

We usually recommend copper IUDs, but that's not feasible in all women.

<40y/o female w/ initial biopsy showing G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 copies/nucleus.)...

Healthy 67 y/o woman, 1.5cm tumor, grade 3

Patient was given ddAC + T

Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?

Would you choose to incorporate HER2-targeting agents, chemotherapy, endocrine therapy, or a mix of these?

Are there particular patient characteristics (e.g. age, ER%, Ki67, grade) that make you more likely to choose neoadjuvant endocrine therapy?

Would a pCR to neoadjuvant chemotherapy change your management? (ER <5%, PR <5%)

Do features such as nodal involvement, Ki-67, degree of ER positivity, etc. change your management? Would you use any gene expression assays to help y...

Would you prefer TCHP over TCH? Would you consider adding an anthracycline?

How would you approach additional systemic therapy? Would the clinical stage of the cancer affect your management?

Is adjuvant radiation and/or adjuvant chemotherapy indicated? 

Would you consider an Oncotype or Mammaprint? Would your management change if the patient had 1-3 positive LNs on SLNBx (as opposed to ALND)?

Would you send Oncotype during chemotherapy if not sent already? Would you stop adjuvant chemotherapy if a prior Oncotype was 25 or less?

For patients with low risk, early stage, HR+/HER2- breast cancer who initiated endocrine therapy in order to delay their surgery due to the COVID 19 e...

What is your specific therapy choice and duration?

Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?

 Would you consider gene profiling to determine need for chemotherapy?

How would you balance the competing risks of these two diagnoses in her treatment?

Patient had a clinical T2N0 cancer at diagnosis, completed 6 cycles TCHP, and had 0.2mm residual disease with 80% cellularity, negative sentinel node.

How do clinical risk and Mammaprint/Oncotype scores affect your decision?

For example, will you recommend a certain vaccination timing in relationship to their treatment? Any concerns for reduced immune response or risks of ...

Given the data from KEYNOTE-522, would you try to incorporate chemotherapy in the treatment regimen?

Does tumor size impact your recommendation? High grade? Young patient age?

Does lymph node positivity change your management?

Would you consider ALND and /or XRT to axilla?

Patient case is triple positive inflammatory breast cancer

Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy. 

Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...

Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.

Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?

Would your answer change if the new lesion is ALH/ADH?

She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?

Patient completed adjuvant AC-T 8 months prior to recurrence. BRCA negative, foundation medicine NGS pending. 

PD-L1 is low and she has residual neuropathy from neoadjuvant paclitaxel.

Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.

Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?

If yes, would you offer tamoxifen or ovarian suppression plus AI?

This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...

Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...

Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?

What chemotherapy regimen would you recommend? 

If so, after how many cycles of chemotherapy would you switch?

Does hormone receptor status impact your decision?

Would you forego anthracycline?

Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?

If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?

If so, how frequently?

Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.

(For instance, TCX4 instead of AC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemotherap...