Breast Cancer - Episode 2

Case 1: Decision Making in Early Stage HER2+ Breast Cancer

Targeted Oncology

Ian Krop, MD, PhD: Hope, I think you want to talk a little bit about how to proceed in cases like this?

Hope Rugo, MD, FASCO: Thanks very much for presenting that interesting case. We’ll have the chance to talk a lot more about the treatment decisions as well.

First, I just want to hear from everybody—just 1 quick sentence each—about who drives decision making. How is the role of the surgeon and medical oncologist related to making decisions in early stage HER2-positive breast cancer? Tiffany, what do you do at your institution?

Tiffany Traina, MD: We proceed with a multidisciplinary approach and recommend close communication between our surgeons and medical oncologists. For a patient with an early-stage HER2-positive breast cancer tumor greater than 2 cm, or node-positive disease, we are traditionally following a neoadjuvant approach. Regardless, the patients will meet with both the breast surgeon and breast medical oncologist at the beginning when establishing that treatment plan.

Hope Rugo, MD, FASCO: Adam, is the process the same at University of Pittsburgh Medical Center?

Adam Brufsky, MD, PhD: We do almost exactly what Tiffany does. I think for T2 and above, or node-positive disease, we’ll start with neoadjuvant therapy. They will see both a surgeon and the medical oncologist at the same time, or within a day or 2 of each other. We actually have guidelines. We follow the ClinicalPath [formerly Via Oncology] guidelines. Just about everybody who is T2 and above, or node-positive, will get the neoadjuvant approach.

Hope Rugo, MD, FASCO: Ian, I assume there is a similar routine at Dana-Farber Cancer Institute? You have a tumor board. Do you include your surgeons in the tumor board?

Ian Krop, MD, PhD: Like the rest of our colleagues on this panel, we do have a multidisciplinary approach for managing all patients with invasive cancer. They meet with the medical oncologist and a surgeon at the time of their initial presentation. In this case, as we’ll discuss, this is a patient who’d benefit from the neoadjuvant approach. But there are other patients for whom decision making is a little bit more complicated.

I think that’s why it’s really important to have both a surgeon and a medical oncologist together for that initial discussion. We also have a separate multidisciplinary tumor board for complex cases in which review of pathology in real time is helpful. But even when we meet the patient for the first time, we try to always have a surgeon and a medical oncologist together.

Hope Rugo, MD, FASCO: That’s interesting. That’s a great approach. We all work in the same clinic, but we do see patients at different times just so that the work-up is done. When we all sit in the same room, it helps a lot and has worked for making decisions for neoadjuvant therapy.

Transcript edited for clarity.