Breast Cancer: The Evolving Neoadjuvant and Adjuvant Treatment Landscape

Transcript:

Joyce A. O'Shaughnessy, MD: [Showing slides] Let's go on to some of the new data sets that have come out from important phase 3 trials that have basically changed our practice. I'll make a few comments of where we have been historically. I'll start with TNBC [triple negative breast cancer], wherewe're in the curative setting looking at adjuvant and neoadjuvant approaches. We've been using more preoperative chemotherapy. The BrighTNess trial showed us an improvement in not only PCR [pathologic complete response] rate but an improvement in event-free survival if we add carboplatin to preoperative paclitaxel followed by AC [Adriamycin (doxorubicin) and cyclophosphamide]. We've worked our way up to 4 drugs in the preoperative setting with patients don't have a PCR. We've been using capecitabine because a couple of meta-analyses have shown an improvement in overall survival in these patients with TNBC who have residual disease.

We’ll look now at the KEYNOTE-522 trial in a moment about the new standard of care, which is to add the pembrolizumab to the stage 2 and stage 3 patients, which is welcome, but we're still utilizing the anthracycline. At ASCO [American Society of Clinical Oncology] March 2022, we will see Dr Priyanka Sharma from the University of Kansas Medical Center in Kansas City, Kansas, who has done a preoperative single-arm study called the NeoPACT trial of docetaxel, carboplatin, and pembrolizumab in patients with stage 2 and stage 3 breast cancer. We'll see how those data compare in a cross-trial comparison with the KEYNOTE-522. We still don't know for sure that we need 4 chemotherapy drugs plus pembrolizumab to get the highest PCR rate for these high-risk triple-negative patients. In the hormone receptor-positive HER2-negative patients in the curative setting, the first question is always, do they need chemotherapy? As Sarah already mentioned, we’ve got the 21-gene recurrent score, the 70-gene prognostic signature, and the MammaPrint assay. We utilize those gene expression profiles to identify patients who need neoadjuvant or adjuvant chemotherapy. With the SOFT [Suppression of Ovarian Function Trial] and TEXT [Tamoxifen and Exemestane Trial] trials, we have been optimizing endocrine therapy for the premenopausal patients, adding an LHRH [luteinizing hormone-releasing hormone] agonist to an aromatase inhibitor for the highest risk patients. We've been increasing the duration of endocrine therapy to 10, or even sometimes, 15 years, for the highest risk node-positive patients. However, we still had this issue with both early and late recurrence. We'll look at the monarchE trial bringing adjuvant and abemaciclib to appropriate high-risk patients. That has been where we have been, and now we’ll look at some very important and recent phase 3 trials in the curative setting that have changed our practice.

Transcript edited for clarity.