NCI-CCC Breast Tumor Board Question   

Patient is BRCA 1/2 wild type; completed four cycle of Carbo/paclitaxel and two cycles of AC with pembrolizumab in the neoadjuvant setting.  

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.

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

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.

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

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. 

(assuming they meet MonarchE criteria) For example, if the patient is in year 2, 3, 4, or 5 of adjuvant endocrine therapy versus 9 months out, would ...

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 ...

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 ...

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?

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

Largest invasive focus is 0.4mm

CNS recurrence occurred within two years of prior neoadjuvant therapy

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?

Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?

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, hormone receptor positive, HER2 negative breast cancer who initiated endocrine therapy in order to delay thei...

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 ...

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

What factors would determine your consideration of this as a recurrence versus a new primary and how would that influence your decision?

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?

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

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...

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? 

Does hormone receptor status impact your decision?

Would you forego anthracycline?

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...