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BCC 2021 | Tailoring neoadjuvant and adjuvant therapy in TNBC

Lisa Carey, MD, FASCO, University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC, discusses the optimal tailoring of neoadjuvant and adjuvant therapy in triple negative breast cancer (TNBC). Progress in this setting has come a long way, with recent years seeing a beneficial shift in systemic therapy administration to a neoadjuvant approach. This has allowed optimization of surgical management and tailoring of subsequent medical therapies. Prof. Carey highlights other areas discussed at the St. Gallen Consensus Meeting where questions remain, such as the use of platinum-based compounds and immune checkpoint inhibitors. This interview took place during the 17th St. Gallen International Breast Cancer Conference.

Transcript (edited for clarity)

Optimizing triple negative breast cancer treatment in the early setting, meaning the neoadjuvant and adjuvant setting, has really come quite a long way. The first is over the last couple of years, there’s been an appropriate shift to administering the systemic therapy, which is largely chemotherapy, in the pre-operative or neoadjuvant setting. And that has benefits in a couple of ways. The first is it allows us to actually optimize surgical management, because you can decrease the in-breast extent of resection that’s required...

Optimizing triple negative breast cancer treatment in the early setting, meaning the neoadjuvant and adjuvant setting, has really come quite a long way. The first is over the last couple of years, there’s been an appropriate shift to administering the systemic therapy, which is largely chemotherapy, in the pre-operative or neoadjuvant setting. And that has benefits in a couple of ways. The first is it allows us to actually optimize surgical management, because you can decrease the in-breast extent of resection that’s required. You also can decrease the amount of axillary dissections, thereby preventing lymphedema and reducing risk of some of those morbidities.

It also allows us to tailor the medical therapy. So we learned from CREATE-X, for example, that in patients with residual disease, so cancer left in any of the breast or the lymph nodes after neoadjuvant chemotherapy. If you administer six months of additional chemotherapy with capecitabine, patients did substantially better, from a relapse and a survival standpoint. So it’s a tailoring question and trying to optimize therapy.

I think there’s still some outstanding questions. We can optimize therapy even further, from a surgical standpoint, with the addition of platinums to traditional anthracyclines and taxanes, but it’s not clear that that helps outcome. So you’re helping the surgical endpoints, but not the long-term ones. So it’s a bit of a trade-off. And so I think among the recommendations that I made and that I think were generally thought to be believed by the consensus conference, was platinums in higher-risk patients are appropriate, but not uniformly.

I think the outstanding question that we have right now is the role, at some point, of immune checkpoint inhibitors, which have shown also some augmentation of responsiveness in the breast and the lymph nodes but have unique side effects and toxicities that can [inaudible 00:01:55] and have not yet been shown. The studies are too immature to say whether they impact on outcome. So I think that’s a unanswered question, and we did discuss this in the consensus conference, and generally, the use of immune checkpoint inhibitors, routinely, was thought to be premature.

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Disclosures

Prof. Carey reports institutional financial interests with the following commercial entities: Novartis, G1 Therapeutics, Genetech/Roche, Lilly, Innocrin, Seattle Genetics, Merck, Immunomedics.

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