Chemotherapy With Adjuvant Therapy in Breast Cancer

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Mohammad Jahanzeb, MD: If we look at various chemotherapy regimens used with HER2 blockade, we have an anthracycline-free approach with docetaxel/carboplatin, with an anthracycline-containing approach where you give 4 cycles of anthracycline-based therapy first and then start HER2 blockade concurrently with paclitaxel. We have previously known from the pivotal trial that you do not give anthracyclines concurrently with HER2-blocking agents because that really enhances cardiotoxicity.

So, the least cardiotoxic approach is to avoid anthracyclines altogether, and that’s what I tend to do. I use docetaxel and carboplatin with dual HER2 blockade of trastuzumab and pertuzumab.

If we look at the approval of pertuzumab by the Food and Drug Administration, it was based on neoadjuvant data using pathologic complete response rate for the very first time as a unique endpoint. And there were only 6 cycles of dual HER2 blockade given with chemotherapy prior to surgery, after which patients completed 12 months of trastuzumab total therapy, counting the neoadjuvant as well as the postoperative therapy.

But now with the APHINITY results, we ask ourselves, should we continue it throughout the duration of trastuzumab therapy? And some of us may choose to do that in high-risk patients, patients with a lot of positive lymph nodes. And in other patients where you achieve a pathologic complete response, I would tend to take a more relaxed approach of just continuing trastuzumab and not both drugs because if a large tumor and the lymph nodes have cleared, chances are great that microscopic disease elsewhere in the body will also have cleared.

Transcript Edited for Clarity

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