Her2+   

At initial diagnosis she had T1cN0 disease treated with lumpectomy and SLNB followed by 12 weeks of paclitaxel with 1 year of trastuzumab.

The FDA recently approved trastuzumab deruxtecan (T-DXd) in the second line setting. Given the results of DESTINY-Breast03, what is now the role of TD...

Patient was initially ER positive, HER2 positive. Currently she is on letrozole. Recurrence is ER/PR negative and HER2 positive and developed almost 2...

Given data from metastatic breast cancer trials that show benefit with continuing trastuzumab despite progression.

Which regimen is preferred in second line for these patients? What is the efficacy of TDXd vs tucatinib in CNS metastases?    

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

Given strong TDXd efficacy in these patients is there a role to use it earlier than 2nd line? How does prior Her2-directed and/or taxane therapy...

Would you proceed with KEYNOTE 522 regimen and add anti-HER2 targeted therapy adjuvantly?

Patient is young. Bilirubin normalizes when tucatinib is held, but again increases to grade 2 when it is restarted. Evaluation for hemolysis was negat...

What do you do if LFTs are elevated after one dose of neoadjuvant TCHP (highest ALT >13 times upper limit of normal, normal bilirubin) with prior n...

Would your thinking change if the patient continues to be NED after an unplanned chemo break, e.g. for insurance issues?

Would you consider the discontinuation of either anti-HER2 agent or both?

Although grade 3 toxicity rates were low, ~10.5% experience some degree of ILD, are there strategies to reduce risk before treatment starts? Are ther...

Does this change for PDL1 1-49% vs >50%? Will you be more likely to employ other checkpoint inhibitors before use of HER2 targeting therapy? Or sta...

If NGS was positive would you treat with HER2 directed therapy? Is this a different clone and should be treated as such?

What combination of fluoropyrimidine, PD-1 inhibitor, or trastuzumab do you use?

The patient is intolerant to trastuzumab deruxtecan. In which clinical settings would you consider reintroduction of TDM1?

KEYNOTE 811 showed improved response rate with the addition of pembrolizumab, but very few patients in this study had low PDL1.

Patient is ypT2N1

Would you consider neoadjuvant or adjuvant treatment and if so, which therapies? Patient initially had pT2N0 disease and recurrent disease is also ER+...

How and when do you plan to perform HER2 testing in patients with NSCLC?

How does trastuzumab deruxtecan compare to other HER2 targeted strategies?

How are you thinking about sequencing therapies for these patients (IO vs chemo vs T-Dxd)? Are the data from DESTINY-Lung01 strong enough to warrant e...

Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use?  Do you feel the dosing used in...

Largest invasive focus is 0.4mm

The patient has extensive liver metastases and a high bilirubin. She has not received any prior systemic therapy in the metastatic setting. 

Patient had an initial tumor response to TCHP, but still had significant residual disease present, including positive lymph nodes and residual breast ...

<40y/o female w/ initial biopsy showing G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 copies/nucleus.)...

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...

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.

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.

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