What is your approach to adjuvant HER-2 directed therapy in a patient who developed cardiotoxicity following neoadjuvant TC-HP?   

Depending on the risk of the cancer and how bad the cardiotoxicity was, it may be worth trying to reinstitute HER2-directed therapy. Typically I hold HER2-directed therapy for a month at a time (until the EF gets to 50% or higher at which point I reinstitute) and involve a cardiologist familiar with...

While I agree with a number of the comments above, including omission of pertuzumab if cardio-oncology feels comfortable with rechallenging her with trastuzumab, my recommendations would be tempered by her stage at presentation and response to neoadjuvant therapy - if she had clinical stage II disea...

In addition to the answers above, I would also consider re-challenging with trastuzumab only (without pertuzumab) since the APHINITY data showed only a very small absolute difference in DFS and there is no overall survival benefit demonstrated to date with pertuzumab in the adjuvant setting.  

There is some data that beta blockers can help prevent some cardiac toxicity. I would wait until the EF was greater than 50%; make sure that any cardiovascular comorbidities are managed, and consider a low dose of carvedilol during therapy. However, the EF would need to be monitored after every cycl...

Notably, most women on the pivotal adjuvant North American and HERA studies were able to successfully rechallenge with trastuzumab after a hold due to a "significant" LVEF change while receiving trastuzumab, so i am comfortable with the trastuzumab rechallenge strategy as was adopted on those studie...

I agree with the recommendations above, omitting the pertuxumab and rechallenging with trastuzumab when EF recovers to >50%, optimizing cardiac care with beta blockers and/or ACE inhibitors. When rechallening with trastuzumab, one can consider weekly dosing at 2mg/kg at first, monitoring with ech...