71 year old female with cT1 cN0 cM0 IDC of the right breast, grade 2, ER 5%, PR negative, HER2 negative, Ki 67 24% being referred to medical oncology. MammaPrint and BluePrint results: Basal-type, high risk 1 (index -0.324), probability of pCR 34%. Would you offer neoadjuvant chemotherapy given the low ER expression and high risk genomic score that would warrant chemo anyway? While I do think that chemo would probably make sense in this high risk molecular subtype, im not sure there is a strong rationale for NACT per se. My initial recommendation (prior to Mammaprint) was to do upfront surgery, repeat hormone staining and go from there. Unusual to see triple negative with such low Ki-67%. What are your thoughts re sequence of chemo?
I absolutely agree with you. Since primary tumor seems to be <2cm (and negative lymph nodes), I think upfront surgery makes the most sense. Even if triple-negative, since <2cm, this approach works. Plus, in a 71 y/o, this approach would allow you to potentially de-escalate chemotherapy (rather than doing the aggressive KEYNOTE-522 approach, or even AC-T).
