Do you offer neoadjuvant therapy to a postmenopausal cT1cN0 , HER2+, ER/PR+ breast IDC or recommend surgery first?  

This is currently a very controversial topic, with likely no single straight answer - arguments can be made for both a neoadjuvant approach in light of the KATHERINE trial and for a surgery first approach with treatment de-escalation in light of the APT trial. As others have pointed out, the recent...

I would offer neoadjuvant chemotherapy, especially if tumor shrinkage could potentially change surgical options. In light of the data from the KATHERINE trial, which included patients with cT1N0 tumors, assessment of pathologic response can guide adjuvant therapy decisions such as switching to T-DM1...

If candidate for BCS now and all preoperative workup reveals negative nodes proceed to surgery. If pathology confirms T1cN0 disease you could save the pt carboplatin and extended chemo esp if er/pr+.  Follow up analysis of APT has shown that these pts do well. 

I tend to reserve neo-adjuvant chemotherapy for patients with cT2 or higher if there is no clinical evidence of positive lymph nodes. The results of APT trial that enrolled patients with node negative, HER2 positive breast cancer measuring up to 3 cm in diameter showed excellent disease free surviva...