72-year-old patient with numerous comorbidities including cardiac valvular disease with a normal LVEF in fairly poor health (ECOG1-2) recently diagnosed with locally advanced left breast carcinoma. She has a palpable large mass on exam measuring approximately 8 cm on imaging with a clinically negative axilla. Her biopsy has revealed an ER/PR positive HER2/neu positive invasive carcinoma with a Ki67 score of 49%. She was referred to me for neoadjuvant therapy. I am skeptical that she will tolerate TCHP. Do you generally use an alternate chemotherapy + anti-HER2/neu combination in less fit patients requiring neoadjuvant therapy?
I think it would be very reasonable to use an alternative regimen in her case. Paclitaxel, trastuzumab, pertuzumab (THP) has been used in the neoadjuvant setting with pCR rates of ~55-60%, so that would be a good option. You can then use TDM1 in the adjuvant setting, if no pCR obtained. There are data for neoadjuvant TDM1 as well, although I have never used this and the pCR rates do seem a bit lower than with THP. Endocrine therapy with HP is also an option, but response rates are lower as well, so I would reserve this for very elderly/comorbid patients.
