Case 2 - Reassessing Risk and Trial Fit in Delayed Presentation

The second case introduces a postmenopausal woman with a moderately sized, intermediate-grade tumor and limited nodal involvement who completed adjuvant chemotherapy and radiation and presents several months after surgery, already established on endocrine therapy and hesitant to add further treatment because of toxicity concerns. The faculty reassess her recurrence risk and question whether chemotherapy was necessary in the first place given contemporary genomic assay data, then consider whether adjuvant CDK4/6 inhibitor therapy remains appropriate for patients who forgo chemotherapy based on low genomic risk. The discussion weighs tumor burden, nodal status, and genomic risk together, while acknowledging the potential for overtreatment with agents perceived by patients as easier than chemotherapy. The panel then examines how differences in eligibility criteria between monarchE and NATALEE shape drug selection for a patient who fits one trial population but not the other. The faculty conclude that timing is not a barrier in this case and that agent selection here rests primarily on anticipated tolerability rather than expected differences in efficacy.