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Tracks 4

DR LOVE: Cliff, how would you have treated this patient?

DR HUDIS: First of all, I agree with the decision to perform an axillary dissection. This case failed the sentinel node test, as applied, because the test identified cytokeratin-positive cells in one node.

I suspect that if we entered this patient’s information into the Memorial Sloan- Kettering nomogram, which is on the web, we would obtain a 10 to 15 percent probability of finding additional positive nodes.

In a case like this with a 9-mm, ER-positive tumor, I would generally use hormone therapy alone, not chemotherapy, except that we do have the tiny warning — the cytokeratin-positive cells in one node — that her risk may be higher than expected.

DR LOVE: Would you order an Oncotype DX^® assay for this patient?

DR HUDIS: I would have a long conversation with her, and if she were willing to consider chemotherapy, and only in that setting, I would order the Oncotype DX assay. I would discuss a prestated plan agreeing that if her score was above a stated threshold, we would use chemotherapy and if her score was below that number, we wouldn’t. However, if the test results would not be used to adjudicate our decision, then I wouldn’t use it.

DR LOVE: Sandy?

DR SWAIN: I’m not as militant about the use of the Oncotype DX assay as Cliff. I order the Oncotype DX assay for any patient who would have been included in the NSABP-B-14 or B-20 analyses.

This patient is a little different in that she had cytokeratin-positive cells, which those studies didn’t examine, but she essentially has node-negative disease based on the B-14 and B-20 criteria (Mamounas 2005).

Even though this tumor is well differentiated and more often than not that means we will see a score indicating a low or low-intermediate risk, I would absolutely order an Oncotype assay.

I believe it’s important for the patient to have that information, and I find — except for the 90-year-old with comorbidities — it can change the discussion. When I have this additional information, I find it’s easier to talk to the patient about her options.

DR TETREAULT: I agree with Dr Swain that a theoretical discussion with a patient about chemotherapy before you have a Recurrence Score^® can suddenly become irrelevant when you have that piece of paper and you say, “Your risk of recurrence is X percent.” Patients then make completely different decisions.

DR ASTROW: What do you do when you have a patient with small, strongly ER-positive, Grade I, node-negative breast cancer, examined by an excellent pathologist whom you trust, and the Oncotype DX assay results in an intermediate or high score?

DR SWAIN: We all have to decide how to use the Oncotype DX data, but I believe the biology is important. We can examine the tumor all we want under a microscope. I’ve been doing this for 25 years and we can be wrong, whereas Oncotype DX examines the biology of that particular tumor more clearly. I would go with the Oncotype result.

DR LOVE: Cliff, are you willing to consider Oncotype results for a patient who clearly has a node-positive tumor?

DR HUDIS: I am. The younger the patient, the less interested I am likely to be in the Recurrence Score to adjudicate this decision. However, the more undecided a patient is about chemotherapy and, especially as patients age, I believe it’s reasonable to extrapolate, with the proviso that all of the node-positive data that we’re basing this on is only a small amount (Albain 2007; [1.7]).

DR LOVE: Dr Towell, what happened with this patient?

DR TOWELL: An Oncotype DX assay was performed and her Recurrence Score was 20, which translated to a 13 percent risk of recurrence. Based on that, she decided to receive chemotherapy. She received four cycles of TC followed by anastrozole.

DR LOVE: Sandy, considering this patient was premenopausal prior to her hysterectomy/oophorectomy, would you have used tamoxifen or an aromatase inhibitor?

DR SWAIN: Tamoxifen has a different mechanism of action, and it may be the correct choice for patients like this. We’re testing that in SOFT and other trials. For premenopausal women, I usually recommend tamoxifen, and I would have done so for this patient.

DR LOVE: Cliff, what hormonal therapy would you administer to this patient?

DR HUDIS: I also would probably have used tamoxifen. It seems abrupt to take somebody from menstruating to surgical menopause and then use an aromatase inhibitor.

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