Tracks 1-14

Track 1 Case discussion: A postmenopausal woman with node-positive breast cancer who received extended adjuvant hormonal therapy Track 2 Risk of recurrence for patients with hormone receptor-positive disease after five years of treatment Track 3 Individualizing treatment options for patients who have completed five years of adjuvant hormonal therapy Track 4 Aging, use of aromatase inhibitors and joint pain Track 5 Clinical disease management for premenopausal patients who have completed five years of adjuvant hormonal therapy Track 6 Case discussion: A 60-year-old woman with hormone receptor-negative, HER2-positive breast cancer who received adjuvant chemotherapy and trastuzumab Track 7 BCIRG 006 adjuvant trastuzumab trial: Docetaxel/ carboplatin/trastuzumab (TCH) Track 8 Risk of congestive heart failure with adjuvant trastuzumab Track 9 Acceptance of adjuvant trastuzumab therapy by patients with HER2-positive early breast cancer Track 10 Use of adjuvant trastuzumab without chemotherapy Track 11 Quality of life and side effects with trastuzumab Track 12 Importance of obtaining adequate tissue for assessment of HER2 and ER status Track 13 Selection of patients for neoadjuvant therapy Track 14 Treatment approach to residual disease after neoadjuvant chemotherapy

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Tracks 1-3

DR LOVE: How did you approach the discussion of further endocrine therapy with this patient?

DR RUGO: At that point, she was six and a half years from her diagnosis of node-positive disease. Since she started therapy, the data have changed. We now understand more about the natural history of hormone receptor-positive breast cancer.

We understand that if approximately 50 percent of recurrences occur after five years, then a substantial residual risk remains. The residual risk for those patients will not be decreased much by the one or two years that she was off therapy. It’s clear that hormonal therapy might provide additional benefit.

Data from MA17 demonstrated that women who allocated themselves to letrozole after unblinding did well compared to women who did not (Robert 2006; [4.1]). This suggests that if you start hormone therapy — even eight years after diagnosis — you may affect patients. For some patients who didn’t receive tamoxifen early on, you can still start an aromatase inhibitor at a later time if they have higher-risk disease.

DR LOVE: Was she surprised when you broached the issue of hormone therapy, considering she had been doing so well for the last seven years?

DR RUGO: Yes. Women want to believe that five years is a magic time period. They don’t want to hear that 50 percent of their recurrence risk — and, in truth, more than 50 percent of their risk of dying — lies ahead of them.

I have a patient who had a 1.9-cm, intermediate-grade, node-negative tumor. She received CMF, went into menopause in her mid-thirties and then received five years of tamoxifen. When she reached her five-year point, I said, “You are in menopause and could take an aromatase inhibitor.” She said, “I had a Stage I tumor, so I don’t believe that’s worthwhile.” Three years later, she had metastatic disease to her bone.

Without concrete data, which we’ll never have, I tailor the duration of the aromatase inhibitor therapy to the extended risk. I say, “Okay, you had node-negative disease, but an aromatase inhibitor adds to tamoxifen in every single trial that’s available. Why don’t we use two or three years of an aromatase inhibitor?”

If a patient has higher-risk disease, it brings up the next point: What do you do with a patient at particularly high risk who’s been on five years of an aromatase inhibitor from diagnosis? Do you continue or stop?

In some ways, it’s like stopping trastuzumab at one year for a patient who has inflammatory breast cancer and positive margins. At five years, I often continue the aromatase inhibitor, although it is impossible to know the optimal duration.

Track 12

DR LOVE: Can you discuss the issue of HER2 testing?

DR RUGO: It’s important to have adequate tumor tissue to make these assessments. I have had patients come in with inadequate tissue sampling — primarily women who underwent a fine-needle aspiration for diagnosis — who then received neoadjuvant therapy and underwent surgery, and nobody rechecked any of the tumor markers.

For HER2, if an immunohistochemistry (IHC) test is performed at a low-volume institution, you always want to repeat the IHC or obtain a fluorescence in situ hybridization test to pin down whether or not the patient has HER2-positive disease. It’s critical to have that information as soon as possible in order to help with treatment decisions.

You don’t want to be treating a woman who doesn’t have HER2-positive disease with trastuzumab. However, you wouldn’t want to miss administering trastuzumab to a patient who has HER2-positive disease.

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Editor:
Neil Love, MD

Interviews

Melvin J Silverstein, MD
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David M Hyams, MD
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Charles E Geyer Jr, MD
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Hope S Rugo, MD
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Highlights of a CME Symposium Held in Conjunction with The American Society of Breast Surgeons Eighth Annual Meeting
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A CME Audio Series and Activity

Faculty Disclosures

Editor's Office