cancer
DR BEKAII-SAAB: Neoadjuvant, or the more correct term is perioperative chemotherapy, giving chemotherapy before and after surgery, has a well-established role from the MAGIC trial, prior to the resection of gastric cancer.
In terms of HER2-positive gastric cancer perioperatively, whether there is value to adding trastuzumab or not is actually something under investigation. On a personal note, although this is outside the label, for at least younger patients where I want to be aggressive, I do tend to actually add trastuzumab to a taxane-based regimen in HER2-positive gastric cancer.
DR LOVE: That’s interesting. Alan, would you use trastuzumab as neoadjuvant therapy in gastric cancer?
DR VENOOK: Great question. Don’t know the answer. I think if that would be done as a study, ad hoc, I probably wouldn’t use it outside of a study. But I think neoadjuvant therapy is, of course, for most of us, a standard. But I would probably not use trastuzumab in that setting.
DR GROTHEY: As I said, a great question. Have I done it? Yes. Would I consider this standard of care? No. I mean, adding trastuzumab. I do use neoadjuvant perioperative chemotherapy according to MAGIC. We should point out for, at least for a GE-junction cancer, there’s an Intergroup trial up and running, an RTOG trial, looking at radiochemotherapy with trastuzumab for HER2-positive cancers in the perioperative fashion, actually. So it shows it’s an area of investigation.
Would I consider this, again, as something intriguing with a larger bulky tumor that hasn’t metastasized, using trastuzumab? Yes.
DR LOVE: Charlie, have you or would you use trastuzumab as a neoadjuvant therapy in gastric cancer?
DR FUCHS: I have not used it. And we have a study open, but I haven’t had a chance to enroll anybody on it.
DR LOVE: So you would give the patient, for example, chemotherapy without trastuzumab?
DR FUCHS: Correct. In the absence of data, I would not give trastuzumab in the adjuvant setting.
DR BEKAII-SAAB: Let me throw a scenario. What if you have an actual patient who’s quite symptomatic from their tumor, a younger patient with a symptomatic tumor, where a response rate is needed, that’s HER2-positive. I would argue that for that particular patient, you are relatively justified to use trastuzumab in addition to chemotherapy, because you improve your response rate. And you know the symptoms are related to the bulk of the tumor.
DR GROTHEY: Neoadjuvant.
DR BEKAII-SAAB: Pre-adjuvant. Perioperative.
DR GROTHEY: Exactly. Not adjuvant, but –
DR BEKAII-SAAB: Not adjuvant.
DR FUCHS: With somebody with an existing tumor. Certainly, if they were borderline resectable and I thought I was treating locally advanced disease, I’d consider it.
DR LOVE: Matt, what’s your take on this? I mean, we’re not going to add much toxicity. I don’t know if you can get trastuzumab paid for, but it shouldn’t be adding much toxicity. Have you done it? Would you do it?
DR KULKE: I haven’t. I mean, I would certainly though consider it in this situation that we were just talking about where you need to get a response. Thinking about it more broadly, does it help in the adjuvant setting? There I would really want to see more data.
DR GOLDBERG: Ditto. I think I would consider it in somebody with locally advanced disease that’s symptomatic and where a response is really important.