Escalation and De-escalation of Therapy Beneficial in HER2+ Breast Cancer

Debu Tripathy, MD, professor of medicine and chair of the Department of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center, discusses escalation and de-escalation of treatment in patients with HER2-positive breast cancer with HER2-targeted agents and chemotherapy.

Tripathy says the goal for these patients is to identify who may not need the same amount of treatment as other patients and de-escalating their therapy. By figuring out which patients are at low risk, they could be given a lighter treatment. The opposite is true as well; patients who at high risk should be identified and should have escalated or more intensive therapy.

Trials have shown that patients with low-risk HER2-positive disease such as those with node negativity and a tumor less than 2 or 3 cm in size, can be treated with paclitaxel and trastuzumab (Herceptin). This is a singular chemotherapy drug, which is given to the patient for about 3 months, in combination with a HER2-targeted agent which is given for a year. Tripathy says this regimen has fewer adverse events than what was used previously.

For patients with larger tumor or node positivity, using 2 chemotherapies and 2 antibodies—docetaxel, carboplatin, trastuzumab, and pertuzumab (Perjeta)—will shrink the patient’s cancer before surgery. After treatment, about half of the patients won’t have any invasive disease left at the time of surgery, according to Tripathy. Although there is still a low risk of recurrence, these patients have shown good outcomes after this type of treatment. Usually, patients will continue on a HER2 antibody therapy after surgery.