DR MORROW: This is a 55-year-old who presents with a 4-cm mass in the upper outer quadrant of a small B-cup breast. She has no palpable adenopathy. The mammogram shows no other lesions. The core biopsy shows this is a classic infiltrating lobular carcinoma. It’s 90% ER-positive, 80% PR-positive and HER2-negative. The patient desires breast-conserving therapy, which she is not a candidate for at the present time based on her tumor-to-breast ratio. What do you tell her? Do you tell her that lobular carcinoma doesn’t respond well to neoadjuvant therapy and she should just bite the bullet and have a mastectomy, give her neoadjuvant chemotherapy, give her neoadjuvant endocrine therapy, get an Oncotype DX® to make up your mind which of those things you want to do?
DR LOVE: How about Ruth?
DR O'REGAN: I think these are the very, very hard cases. First of all, I wouldn’t just immediately give her chemotherapy because we know that she’s not going to have a great response, assuming it’s low grade as well. We actually have had a study using Oncotype’s 21-gene Recurrence Score® to kind of select treatment for these patients, where if the score is over 25, they get chemotherapy. If it’s less than 10, they get preop endocrine therapy.
DR LOVE: If you did send for an Oncotype and it came back high, would you give her chemo?
DR O'REGAN: I’d feel more comfortable about doing it, although I think it would be very unlikely that it would come back high. But I just don’t think these patients respond very well to chemotherapy.
DR LOVE: Bill, what would you be thinking about in this situation?
DR GRADISHAR: I’d be thinking along similar lines. I think if you were trying to avoid a mastectomy in this patient and trying to get her to a point where she could have breast conservation, then doing a Recurrence Score would provide justification for giving her endocrine therapy. If the Recurrence Score was absent or you didn’t do it, for whatever reason, I think you could try endocrine therapy. But the point is — and I think Ruth made it nicely — if you’re going to be committed to that, you have to stick with it. It’s not going to be the kind of thing that you’re going to clinically, using clinical endpoints, be able to make a judgment on after 4 or 6 weeks. You’re going to have to stick with it and, as long as there’s not progression, continue with it.
DR LOVE: Monica?
DR MORROW: If I could just add one comment, which surprised me. The Austrian Breast Cancer Study Group published in a surgical journal recently the outcome of lobular cancers in their neoadjuvant trials and showed that, although, as Ruth said, path CR was extremely uncommon in the chemotherapy group, that they actually were able to downstage about 80% of patients to breast conservation, which is a much higher number than we might expect and makes you wonder how much they needed a mastectomy in the first place.
What happened to this patient was that she was treated in a setting where she wasn’t going to get neoadjuvant endocrine therapy, which is to say she was treated at my institution, where there is not a lot of enthusiasm for that other than in the very elderly and patients with comorbidities. So what I told her was that the characteristics of the tumor were such that classically they weren’t associated with a great response to chemotherapy and that it was not clear from her preoperative characteristics whether or not she would receive chemotherapy postoperatively, that that would depend on things we didn’t know, like her nodal status and, ultimately, her 21-gene Recurrence Score. And after hearing all that and speaking to the medical oncologist about what would be involved in the neoadjuvant therapy, she ultimately underwent a mastectomy with an immediate reconstruction.
DR LOVE: What was seen pathologically and what kind of postop treatment did she get?
DR MORROW: Pathologically she did, indeed, have basically a classic lobular carcinoma. There were no pleomorphic areas. Her sentinel nodes were negative. And her 21-gene Recurrence Score was a score that would have been classified as low under the company’s original score distribution and intermediate under the TAILORx classification of risk. So she was advised that falling into that category outside of a clinical trial, the standard default was chemotherapy, which she declined to receive.
DR LOVE: What chemo was advised, incidentally?
DR O’REGAN: Dose-dense.
DR MORROW: No. She was advised to receive —
DR RUGO: CMF.
DR MORROW: — CMF times —
DR RUGO: CMF.
DR LOVE: Adam, would you have done an Oncotype on this lady postop?
DR BRUFSKY: She’s node-negative?
DR MORROW: She was node-negative.
DR BRUFSKY: I would have even done it if node-positive. That’s beside the point. I think I would have done an Oncotype postop. I would have used the 18. If you’re going to give CMF, give CMF. That’s what was given in B-20. So, if you’re going to go whole — do it. You might as well go the whole way.
I don’t think this woman needed chemotherapy. I wouldn’t have given her chemo. I wouldn’t even advise her to get chemo. I would have told her the risks and benefits. I would have said, “Listen. We don’t know for sure. Your Oncotype is in between. What used to be 18, it’s now 11. Anything to me under 18 really doesn’t have any benefit to chemo.” I’d have put her on an AI and called it a day.
DR LOVE: Hope, with a 4-cm infiltrating lobular, would you have done an Oncotype in the postop setting?
DR RUGO: I probably would do an Oncotype — a Recurrence Score — in that situation because I think that when we looked at our patients in the neoadjuvant setting who had lobular cancer, we did see more responses than I would have thought. Nothing like the Austrians, but the classic small lobulars, Grade Is, ER/PR-positive — don’t do anything. But there is a pleomorphic group and a heterogeneity in that tumor, and there’s a small percentage of patients who have higher scores.