The Role of Neoadjuvant Chemoimmunotherapy in Stage I TNBC

Keerthi Gogineni, MD, MSHP, discusses the use of preoperative chemoimmunotherapy in patients with stage I triple negative breast cancer.

Keerthi Gogineni, MD, MSHP, associate professor, Department of Hematology and Medical Oncology, associate director, Hematology and Medical Oncology Fellowship Program, and co-vice chair of Diversity, Equity, and Inclusion, Department of Hematology and Medical Oncology at Emory University School of Medicine, and director for Education of Fellows and Residents at Grady Health System, discusses the use of preoperative chemoimmunotherapy in patients with stage I triple negative breast cancer (TNBC).

The role of neoadjuvant chemoimmunotherapy is best demonstrated in the KEYNOTE-522 trial (NCT03036488), according to Gogineni. In the study pathologic complete response rates with higher in patients with early TNBC when neoadjuvant or adjuvant pembrolizumab (Keytruda) was added to standard-of-care chemotherapy.


0:08 | The rationale that I provided for considering preoperative therapy, even in the setting of small cancers, and when I defined small, I was really focusing on the women who had cancers between one and two, seven years. However, I think there's some argument that could be made as well for people who have cancers that are six to nine millimeters. And I'll go into that in a second. But the main rationale that I had is that we deliver preoperative therapy to women that have triple negative disease. The knowledge we gain from their response to the therapy at the time of the surgery, what their pathologic results really can be instrumental in terms of reducing their risk later.

0:52 | We know that women who have triple negative breast cancer who don't have a pathologic complete response at the time of surgery, really have very high risk of recurrence and high risk of death over the next 3 to 5 years. So, identifying who is in that high risk group, the only way that we can really do that is by testing with giving them preoperative chemotherapy and seeing what that pathologic response was.

1:19 | There's a couple of trials that kind of demonstrate that poor prognosis in women who don't get the pathologic response. And then these include meta-analyses that were performed for the FDA, as well as more modern analyses. Also, there are the results we have from the KEYNOTE-522 trial. This was a clinical trial that looked at preoperative chemoimmunotherapy in patients who had tumors that were at least 2 centimeters in the breast or were lymph node positive. And in those women, we saw that the combined regimen of chemoimmunotherapy did result in higher pathologic complete response. Those women had a 65% chance that they were going to have a pathologic complete response. And that corresponded to an event view survival rate of about 85% at the 3-year mark. But in the 35%, you didn't get the pathologic complete response in that more aggressive arm. We saw that their survival rates were actually 67%. So, when we think about that, there's a huge amount of room for improvement and trying to mitigate this patient's adverse prognosis and we can use different adjuvant strategies to try to lower their risk, but we have to be able identify who's at risk first.