Risk Factors and the Treatment Plan


Rachel Layman, MD, describes her impression of the case and discusses risk assessment and a treatment plan for the patient.


Stephanie Graff, MD, FACP: What do you think about this patient’s risk? And what parameters are you going to be considering?

Rachel Layman, MD: Unfortunately, I think she’s at high risk of recurrence. I’m glad to hear that her staging scans did not reveal any evidence of distant metastatic disease. She’s a very young premenopausal woman. Despite the tumor being fairly small, there was significant lymph node involvement with N2 disease and the Ki-67 [score] is high.

When I’m thinking about parameters, I think about menopausal status, the amount of nodal involvement, and, to a lesser extent, the size of the tumor. I also look at parameters related to the biology of the tumor; looking at grades, the Ki-67 and the extent of hormone receptor positivity. In this case, both the estrogen receptor and progesterone receptor were positive and were fairly high. So that is more favorable. Tumor molecular profiling tasks like Oncotype DX might be helpful in some situations, but I probably would not order it in this case, because she’s going to need chemotherapy anyway, given that she’s premenopausal and has significant lymph node involvement.

Stephanie Graff, MD, FACP: I agree. I don’t tend to order molecular profiles like Oncotype [Dx] or MammaPrint on patients with this extent of nodal disease, especially premenopausal patients with this extensive nodal disease. Because sometimes, as one of my mentors used to say, “Don’t ask questions that you don’t want the answer to.” And this is definitely one of those scenarios.

Obviously, this is a patient who I would be giving adjuvant chemotherapy to. I think [because] she is a patient with N2 disease, I would have a bias toward anthracycline, there’s probably some national discrepancy on whether you would do an anthracycline or a nonanthracycline regimen here. I think guidelines would likely support either approach, and there’s probably some training bias in which direction you go for those patients. Then again, with positive lymph nodes after breast-conserving surgery, she did have a lumpectomy, or again with 5 positive lymph nodes and a mastectomy in a 39-year-old, I would also recommend adjuvant radiation. [Do you have any] comments on those initial steps before we dive into the endocrine therapy conversation, which is really the heart of what we’re doing here?

Rachel Layman, MD: Yeah, I completely agree. I think she certainly requires chemotherapy. I would favor an anthracycline-based regimen with a taxane as well. I think it would be appropriate and reasonable to give an anthracycline-sparing regimen like taxotere-cyclophosphamide, but I think in this case, I would favor doing AC [anthracycline] followed by weekly paclitaxel, or dose-dense paclitaxel. And I typically give the AC dose-dense.

Transcript edited for clarity.

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