How would you approach systemic therapy for a pre-menopausal woman with ER+/PR+/HER2 positive breast cancer who had a local recurrence 6 months after completing adjuvant TCH and a year of trastuzumab + tamoxifen?

This patient has high-risk disease.

First point:

Option 1: Since the cancer recurred 6 months from TCH, I think you can justify using TDM-1 and pertuzumab combination based on I-SPY 2 data (pCR achieved in 52% for women treated with TDM-1 and pertuzumab versus 22% for women treated with trastuzumab ...