Do you use trastuzumab for patients with localized HER2+ esophageal cancer after definitive chemoRT who are not surgical candidates?

There is currently no good evidence to support use of trastuzumab as a single agent in esophageal cancer, much less with or following definitive chemoRT. The RTOG 1010 trial will help us to understand the role of trastuzumab in trimodality therapy setting. Based on current evidence, I typically would treat with definitive chemoRT (for the unfit surgical patient) while checking PDL1, MSI, HER2 for future treatment planning (given high risk of recurrence/progression with chemoRT alone). Then I would use trastuzumab along with first line therapy if there is a recurrence.

I agree with @Dr. First Last. The RTOG 1010 study is the only study that has addressed the benefit of adding trastuzumab to chemoradiation. Patients were randomized to receive trastuzumab along with chemoRT but also as adjuvant treatment following surgery. While there have been no safety signals, the data have yet to be presented despite the study completing accrual at least 3-4 years ago.

Therefore, unburdened by data, there are essentially 2 options: to omit trastuzumab on the basis of no proven efficacy or to add it to chemoradiation based on safety. I do think both approaches are defensible and, as with many situations, we all have to wrestle with what to do when data are lacking.

Having written that, I would clarify that I would not ad...

At this time, there is no data for adding trastuzumab to definitive treatment in non-surgical therapy for esophageal cancer. While the addition of trastuzumab to trimodality therapy has been explored in RTOG 1010, this study has not been resulted and thus we cannot extrapolate from that trial to the non-surgical setting. In the face of definitive bimodality therapy, I would not use trastuzumab in combination with chemoradiotherapy but would check biomarkers as the likelihood of cure after this treatment is low.