This spring at the 2017 ASCO Annual Meeting, a trial called APHINITY was unblinded. This was a trial that asked the question of [whether there is a] benefit of double targeting HER2 in ER-positive, node negative, earlier stage breast cancers. The trial met its endpoints, it showed that across the board there was a benefit in double targeting. But, in subsets, the benefit was quite minimal. So now, there are a lot of questions being asked about where the line in the sand is—when am I going to recommend double targeting? I don’t think we know the answers to that yet, it might be the tumor size, where larger tumors will benefit from double targeting. I think that bears watching now in the HER2-positive space.
As a surgeon, what are your thoughts on chemotherapy in this setting?
I think that we do not use neoadjuvant strategies in this country as much as we should. And I am including everything from cytotoxic chemotherapy, to HER2 blockade, to estrogen blockade. We don't think about it upfront, but as surgeons we must. If we start the process with surgery every time, then we lose the ability and the benefits of neoadjuvant therapy. And the benefits are very clear. First there is an in vivo response so you can see that the agents are working, and then the surgery becomes smaller with a decreased tumor burden. So, for a lot of reasons I think that neoadjuvant treatment should be the future, and frankly it should be the present.