Patrick I. Borgen, MD
The tradition of lively Medical Crossfire debates continued at the 33rd Annual Miami Breast Cancer Conference this year, with three bouts involving four physicians.
Here are the questions and a summary of what the combatants had to say.
Should platinum-based or other additional systemic agents be used in high-risk triple-negative breast cancer (TNBC)?
Matthew Ellis, MD, PhD
Yes. The question of how to augment standard chemotherapy to reduce the risk of recurrence in very high-risk cases—especially TNBC—remains a challenging one: some oncologists already are using platinum agents in this way. Promising findings of studies were presented at ASCO and SABCS (eg, CALGB 4063, GeparSixto), showing the number of patients achieving a complete pathologic response is higher with neoadjuvant carboplatin in TNBC. Researchers are awaiting more data from two large trials to confirm a survival benefit.
Debu Tripathy, MD
No. It is too early to routinely recommend additional chemotherapy in patients with high-risk TNBC. Studies assessing the addition of platinum agents in the neoadjuvant setting do show higher complete pathological response, but the more relevant benefit of adjuvant chemotherapy is long-term impact on recurrence and mortality.
This has not yet been shown when using a standard chemotherapy backbone. One recently presented but not yet published trial (CREATE-X) does deserve some attention. It involves the use of capecitabine in patients who have residual disease after neoadjuvant chemotherapy. This trial enrolled both hormone receptor–positive and –negative, HER2-negative cancers and showed improved survival over the control arm with 6-8 cycles of capecitabine postoperatively.
Once published and subjected to commentary, this could either with confirmation or on its own represent a potential treatment, but only after neoadjuvant therapy—as residual disease could identify those most likely to benefit.
Is it time we stopped offering mastectomy to patients with breast cancer?
J. Michael Dixon, MD
Yes. At one time, you used to say that breast conserving surgery was at least equivalent to mastectomy. It’s now looking better for some patients than mastectomy, and there are reasons for that because mastectomy is not the best operation.