Breast cases.

In the past years we saw many new studies in local treatment of breast cancer.

First case. 55 year old woman with a 1.5 grade 2 IDC ER+ HER2 neg, no LVI, she has a lumpectomy, SN biopsy, she has AD. In total she has 3 out of 18 positive nodes. The recurrence score is 15. For adjuvant systemic therapy the options are AC, TC, ACT, HT alone.

83% would do ACT followed by HT. 

I which ER positive patient I get an oncotype. I think that oncotype is a reasonable test to get. If there is not a choice to be made about ChT there is no reason to get an oncotype. This is a pt who would have been eligible for the old SWOG trial that looked at CAF plus T versus T. In that trial in a retrospective analysis oncotype was predictive of the benefit of ChT. Many people are less comfortable moving forward with a no ChT approach because the absolute benefit is larger. That said 15 is a pretty low score. In the clinical trial we redefine what is a low oncotype score like in the tailor X study where no or low ChT score was 10 or under. 18 or under is a low oncotype score. In both retrospective studies it was associated with no or minimal benefit from ChT.

I think in this situation you can make a reasonable argument to differ ChT and HT. You can make argument to give ChT alone. IN a trial pats with node positive disease are randomized to receive HT alone or HT plus ChT. That trial includes pts who has an oncotype score between 0 and 25. I would have a conversation with these pts. 

The other issue is that if you decide to give this pt ChT the question is if ChT followed by HT is the appropriate regimen. Pts who have a low oncotype score do pretty well. BC specific mortality for pts for pts with low oncotype score after AC or ACT was 2%. The question is do you need a long regimen. The benefit of taxanes is minimum to none. We could not show an interaction of treatment effect. The HR for recurrent is 1. So essentially no benefit. Probably no benefit from any ChT.

One of the problems wth the SWOG retrospective study is that it is predictive in not giving a benefit from ChT but the risk was pretty high. It has a high risk with HT alone. 

MA 20 I believe it is still a review. The journal asked for updated results. This study was presented 3 years ago at ASCO. 1800 pts 85% had 1 - 3 positive nodes. They were treated with lumpectomy and WBI plus or minus nodal irradiation including intramammary nodes. There was a benefit in loco regional control. The rate of mets at 5 years was low (32% reduction). OS was almost significant. 

The EORTC trial is going to be reported out the next couple of weeks. It is also a positive trial. These 2 studies will have a huge impact in terms of our treatments. 

Let us go back to this pt. Low recurrence score. In terms of irradiation do you do breast tangents, high tangents, tangents and SC and axillary apex, tangents SC and IMN.

In the absence of publications 38% would do breast tangents, 41% would do tangents and SC axillary apex, only 16% would include the IMN. 

I would do breast tangents. 

I would do breast tangents alone. Number 2 is a wrong answer as it targets only the LN that have been dissected. Number 4 would be my second choice. It is a very heterogenous group. MA 20 has influenced us. The probability of having microscopic disease in IMN is high. 

Regional recurrence in pts who had ChT is very low, 2 - 3%. You published a paper on oncotype and loco regional recurrence. 

Second case. It is a 55 year old pt. This pt has LVI. She has 2 of 15 positive nodes both has macro mets. She got ChT and HT. What would you do regarding radiation, tangents, high tangents, tangents + SC + apex of axilla, tangents and full nodal irradiation. It was a grade 3. 

36% tangents, 15% would include IMN. It is in the grey zone. I would have a discussion with the pt. 

I would treat as number 4. She is borderline. 

The improvement in survival with RT is also in the pts with 1 - 3 positive nodes. In pts with 1 - 3 positive nodes you have to do a full dissection. The use of post mastectomy RT has a 10 year gain in recurrence, 15 year gain in mortality. The benefit was similar with 1 positive node, 2 positive nodes and 3 positive nodes.

In this study there is a reduction in recurrence but the mortality benefit is considerably less. 

Third case. 48 pre menopausal women 1.8 cm cancer. Grade 2.  No LVI. She underwent mastectomy. SN node followed by AND, 1 positive node. Macromet. Would you do no radiation, tangents, tangents and SC, tangents and full nodal irradiation. 

14% would do no radiation, 44 tangents and superclav, 30% tangents apex and IMN. 

I would pick one. It is a very favourable case similar to the first case. 

We started to treat with SC about 25% of people with 1 - 3 positive nodes. In the 75% which did not do SC the recurrence rate was less than 5%. 

This pt has a small disease burden. The danish trial is still driving a meta analysis. 

When you consider 1 - 3 positive LN the risk of recurrence is quite low. 

I would pick number 1. 

I would do number 1 as well. We can only look at the results of randomized trials. 

In the more moderns data sets you see lower recurrence rates. We are starting to see a survival benefit. 

Many people would not benefit from ChT. Most of these data are old data.