For anatomic stage III ER/PR+ breast cancer treated upfront with surgery, how do you decide which adjuvant chemotherapy to offer?
What adjuvant chemo would you select for most stage III HR+ breast cancers?
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Anatomic stage III breast cancer includes different clinical scenarios ranging from a tumor over 5cm with 1-3 + lymph nodes, tumors with 4 or more + lymph nodes, tumors with chest wall/skin invasion, and inflammatory breast cancer. For the first scenario, a T3N1 post menopausal female with an Oncotype score below 25 (RxPonder) or a low risk Mammaprint (MINDACT) is unlikely to benefit significantly from chemotherapy. This would be the main scenario where I would consider doing genomic testing. Without genomic testing, the other factors like high grade, Ki67%>15, low ER expression (especially less than 10%), negative PR stains, LVI/ECE can be used to identify higher risk/luminal B cases. If an ER/PR+ T3N1 postmenopausal patient requires chemotherapy by genomic or clinical factors based on the ABC trials, TC chemotherapy could be considered.
For the low ER expressors, N2, T4, or inflammatory breast cancer cases in post menopausal patients or for all four scenarios in premenopausal females, I would not routinely do genomic testing. I would use AC-T in these cases unless there was a contraindication to anthracyclines. We usually give AC-T neoadjuvant for true inflammatory cases.