Summary
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Original Article
Treating Patients With Early-Stage HER2-Positive Breast Cancer
Oncology Times
By Catlin Nalley
Significant treatment advances have been made for early-stage HER2-positive breast cancer. The introduction of adjuvant trastuzumab has improved outcomes in a number of patients. Other approvals in the adjuvant setting, such as neratinib and pertuzumab, have had an impact as well.
Finding the right treatment avenue for this population depends on an individualized approach that considers the specific needs of the patient. During her session at the Miami Breast Cancer Conference, “Individualizing Therapy for Early-Stage HER2+ Breast Cancer,” Sara Hurvitz, MD, highlighted the latest research and advances in this patient population. She reviewed how clinicians can effectively identify those patients at highest risk of relapse and select them for more treatment while avoiding over-treatment of those who are likely cured with standard therapy.
Treatment Evolution
The approach to early-stage HER2-positive breast cancer has evolved with practice-changing data from a number of studies.
“A rising number of patients—especially those with tumors of at least 2 cm in size or node-positive—will receive neoadjuvant treatment with dual HER2-targeted therapy (pertuzumab and trastuzumab) plus chemotherapy given phase II data [from the TRYPHAENA study] showing improved rates of pathological complete response (pCR) with dual blockade, compared to trastuzumab,” noted Hurvitz, Director of the Breast Cancer Clinical Research Program at the UCLA Jonsson Comprehensive Cancer Center and Associate Professor of Hematology/Oncology at the David Geffen School of Medicine at UCLA.
“Moreover, the neoadjuvant setting allows clinicians and patients to test the sensitivity of a tumor to the treatment chosen,” she continued. “Those who have residual disease at the time of surgery will be offered T-DM1 for 14 cycles, based on the impressive results of the KATHERINE trial. Those who have a pCR at the time of surgery will complete the full year of trastuzumab.”
For patients whose lymph nodes were involved by cancer, data from the APHINITY study supports the use of pertuzumab for the full year, according to Hurvitz. “Neratinib is also an option for patients with high-risk (node-positive) HER2+ breast cancer after completing a year of adjuvant trastuzumab.
“The benefit of neratinib does appear to be restricted to patients with tumors that co-express the hormone receptors, and it has not been studied in early-stage disease in patients who have received prior pertuzumab or T-DM1,” she explained.
Challenges & Improving Practice
A key challenge providers face when it comes to caring for these patients is managing the side effects of therapy, according to Hurvitz.
For example, patients treated with pertuzumab have a higher risk of diarrhea and febrile neutropenia during chemotherapy. “[Additionally,] neratinib is associated with a high risk of diarrhea, which can be mitigated through the use of dose reduction (or starting dose low and increasing as tolerated) and use of antidiarrheal regimens.
T-DM1 use in the adjuvant setting can be challenging, according to Hurvitz, due to neuropathy and fatigue as well as thrombocytopenia. “These toxicities should be managed with patient education and close monitoring/follow-up.”
When asked how cancer care providers can improve their practice approach, Hurvitz said, “’Work as part of a multidisciplinary team so that patients are sent to medical oncology prior to surgery to discuss optimal timing of systemic therapy and discuss different regimens available prior to and after surgery.
“Also, clinician education through CME activities is critical now given the pace of new discoveries and the way that standard of care is rapidly changing.”
Catlin Nalley is a contributing writer.