My Treatment Approach: Endometrial Carcinoma - Episode 7
Dr David O’Malley explains when to add and remove trastuzumab during endometrial carcinoma therapy.
Krishnansu Tewari, MD: When do you integrate trastuzumab for that patient?
Bradley Monk, MD, FACOG, FACS: That’s a good question. The patient was HER2 negative.
David O’Malley, MD: As we look at this, without data, yes, I expect that arm is going to do better. I just haven’t taken that leap. I am not advocating using I/O [immuno-oncology] therapy without first utilizing the carboplatin and paclitaxel. In my mind, this patient had already progressed on carboplatin, paclitaxel. I think it’s really important to say, without data, the first-line therapy in metastatic recurrent endometrial carcinoma is still carboplatin, paclitaxel.
Bradley Monk, MD, FACOG, FACS: It’s a shared decision. These are sophisticated people. They know that in a stage IV uterine serous cancer, she’s dead. They want to do everything possible, and they accept the possibility of an immune-related adverse event. It’s a unique situation, and I’m not advocating for it, but the shared decision-making is important. I want to save time for Dave’s case. Why don’t we go ahead and finish up with your case?
David O’Malley, MD: As I pull the case out, I do want to touch on the point Krish mentioned, which is the HER2/neu [human epidermal growth factor receptor 2] testing on those patients who have serous cancer. We have a survival advantage. It was not placebo controlled, but now that the survival advantage has been published by Amanda Nickles Fader, MD, in Clinical Cancer Research about 2 years ago, those patients with any advanced disease, including regional lymph node, benefited, particularly in the first-line setting. It’s really important to keep that in mind regarding serous cancer of the uterus.
Bradley Monk, MD, FACOG, FACS: It’s NCCN [National Comprehensive Cancer Network] recommended, so it’s probably reimbursed and compendium listed.
David O’Malley, MD: Correct. The biggest question for me is, when do you stop in a patient who has stage III disease? Not stage IV—I’m never stopping in stage IV. With a patient with stage III disease, when do you stop the trastuzumab?
Bradley Monk, MD, FACOG, FACS: I’m not sure.
Krishnansu Tewari, MD: I have not had a chance yet to treat anyone with a HER2-positive serous cancer with chemotherapy plus trastuzumab, so I can’t answer that.
Bradley Monk, MD, FACOG, FACS: Help us, Dave. What do you think? A year?
David O’Malley, MD: No, probably 5 to 7 years. These patients have recurrence rates of 60%. They come in once every 3 weeks; the toxicity is very low, it’s annoying for them to come in once every 3 weeks, but I’m going to treat that patient until I think she’s beyond risk recurrence. Clearly, it would take at least 2 to 3 years.
Bradley Monk, MD, FACOG, FACS: OK.
Transcript edited for clarity.