In early-stage ER‑positive, HER2‑negative breast cancer with germline BRCA1 mutation and high genomic risk, how should the choice between neoadjuvant and adjuvant chemotherapy be approached?

I typically do not use the BRCA1 mutation as the determining factor for a neo-adjuvant or adjuvant chemotherapy approach in patients with hormone receptor-positive, HER2-negative non-metastatic breast cancer. However, if the patient's characteristics and their disease would fit the eligibility criteria for OlympiA trial (i.e., for patients treated with upfront surgery with 4 or more positive lymph nodes and for patients treated with neo-adjuvant chemotherapy, significant residual disease based on CPS+EG score of 3 or higher was required), I would offer her 1 year of adjuvant olaparib after completion of chemotherapy and adjuvant radiation.