Her2+   

38 y/o female had a biopsy of a palpable mass that showed G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 c...

Would you use trastuzumab/pertuzumab, trastuzumab followed by neratinib, or another strategy?

Would you choose to incorporate HER2-targeting agents, chemotherapy, endocrine therapy, or a mix of these?

How would your plan differ if the patient could eventually receive mastectomy once co-morbidities improve?

Would you prefer TCHP over TCH? Would you consider adding an anthracycline?

How would you approach additional systemic therapy? Would the clinical stage of the cancer affect your management?

Would you favor 2nd line chemo (with or without trastuzumab) versus immunotherapy?

Is there any safety data to proceed with TKIs/TDM-1 or to proceed as standard with THP?

For patients who remain NED for years, when would you feel it's appropriate to hold therapy?

What would you offer if the patient is not a candidate for cytotoxic therapy?

Patient has progressed through prior lines of endocrine therapy. 

Patient had a clinical T2N0 cancer at diagnosis, completed 6 cycles TCHP, and had 0.2mm residual disease with 80% cellularity, negative sentinel node.

2 populations of cells with 95% negative by FISH (ratio 1.07) and 5% positive by FISH (ratio 10)

Does lymph node positivity change your management?

Patient case is triple positive inflammatory breast cancer

Are there any studies that compare them?

How would your treatment change given pCR rates are reportedly much lower in triple positive patients?

Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy. 

Do you repeat the loading dose of trastuzumab?

Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.

Given the changing landscape of treatment, some patients may have already received capecitabine previously.  Would this impact your treatment rec...

Would you obtain baseline PFT on all patients or only selected high risk patients? Would you repeat PFTs regularly or only if clinically symptomatic?&...

Interest in approach for elderly population especially 

Would you consider an anthracycline based substitution vs changing to nab-paclitaxel or a combination with platinum agent?

Would you recommend additional cytotoxic chemotherapy and/or switch her anti-Her therapy to T-DM1?

Especially if HER2 negative on pathological specimen

Asymptomatic brain progression despite CNS surgery and SRS x2 over the past 2 years.

NCCN gives category 2b recommendation for either ER+ or ER-, HER2+ tumors, from the Tolaney NEJM 2015 paper with trastuzumab/paclitaxel.  However...

N1mic - few isolated malignant cells in 1 axillary lymph node

In cases where patient received 6 cycles of THP and 1 year of HP 

Patient received adjuvant chemotherapy and anti-Her2 therapy 3 years ago.

If yes, would you offer tamoxifen or ovarian suppression plus AI?

Received adjuvant HER2 directed therapy 3 years ago. 

This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...

How would this change if the patient had metastatic HR+,HER2- breast cancer and now has symptomatic pancytopenia secondary to BM involvement after TCH...

The APT trial reported excellent DFS, OS and RFI for tumors <=3cm but few were smaller T2s (2-3 cm) and few were >70 years old.

Stage T1bN1mic

This is a patient with a 1.8cm node negative HER2 positive tumor that is grade 3, high Ki67, and ER positive.

It is included in favorable histologies on NCCN, but no mention of how to treat based off HER2 status.

Patient only had upfront surgery.

Do you utilize it immediately following chemoRT or wait until disease progression?

If yes, would you still recommend dual HER2 directed therapy? After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...

Does hormone receptor status impact your decision?

Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...

The patient received THP and now is on maintenance HP when she developed CNS disease.

Which patients should receive TDM-1, Trastuzumab+Pertuzumab or Trastuzumab alone?

Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab

Any factors that would impact this decision (how far along adjuvant trastuzumab, disease characteristics, etc)?

Only a small subset (22-24%) of patients in Katherine trial received a non-anthracycline containing regimen.

One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone.  How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...

For example, in a patient > 70 years old?

Will you incorporate the results from KATHERINE into clinical practice now?

The CREATE-X trial did not include HER-2 positive patients but the ER-negative population benefited from capecitabine. Would you consider capecitabine...

Would you do a pertuzumab-based regimen or T-DM1?

In light of the KATHERINE data- does this change your practice?

The NEJM 2015 paper by Tolaney et al only included 1.5% of patients with micrometastases.

Would you do this for ER+ patients? According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...

Is there any evidence to use trastuzumab and pertuzumab without doxorubicin?

If so, how frequently?

How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?

Would you consider using CKD inhibitors upfront in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Hercepti...

Would you consider using ckd inhibitors in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Herceptin? NCCN ...

The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.

How does prior Her2-directed and/or taxane therapy affect your decision?

Do you ever consider de-escalating or stopping therapy in this situation? What is your approach to this conversation?