How do you determine which HER-2 positive patients should receive neoadjuvant chemotherapy?

Chemotherapy in combination with anti-HER2 antibodies should be recommended to a patient with node positive, HER2 positive breast cancer. Since NSABP B18 and B27 showed no difference in long term outcomes between patients treated with neo-adjuvant vs. adjuvant chemotherapy, you can go either way. I tend lean towards offering a patient in question neo-adjuvant chemotherapy as this approach can provide us with prognostic information even if it will not affect the surgical choice given a small, T1 tumor. Achieving complete or near complete response to neo-adjuvant chemotherapy is a favorable prognostic factor. In addition, patients who have residual disease after neo-adjuvant chemotherapy may consider enrolling in a clinical trial testing nove...