Would you offer neoadjuvant chemotherapy to premenopausal women with cT1cN0 HER2+ breast cancer?

Since most neo-adjuvant trials required that primary tumor was at least 2 cm, I tend to lean towards upfront surgery. If the tumor size is confirmed and sentinel lymph nodes are negative, the patient could be offered paclitaxel and trastuzumab which is significantly less toxic than pertuzumab in combination with trastuzumab, carboplatin, and docetaxel often used in neo-adjuvant settings.

No. While it would place her in the position of achieving a pCR or using Kadcycla in the event of a suboptimal response, it is more likely to expose her to over treatment. If she is indeed a T1c, the 7 year update of the APT data is very impressive with nearly a 98% DFS. Moreover, if she were found to have more extensive disease, either T2 or N1 disease, we could then give a year of Perjeta as per the APHINITY trial.