NEOADJUVANT CHEMO IN EARLY BREAST CANCER

debate nact vs sx in ebc

1. NACT VS UPFRONT SURGERY IN EARLY STAGE TRIPLE NEGATIVE BREAST CANCER Dr Zaveri Mohinta Fellow Breast Oncosurgery

2. 1 in 8 women develop breast cancer in their lifetime. About 66 % of those diagnosed are EBC. The 5 year survival rate for EBC is 99 %.

3. Triple Negative Breast Cancer Triple-negative breast cancer (TNBC) characterized by the absence of - estrogen receptor (ER ) progesterone receptor (PR ) Her2neu receptor.  Incidence in the West is at 12.2%-13% but in India, several reports have suggested that TNBC incidence is higher and up to 31 %. In our institute- 35.9 % Meta-Analysis of Prevalence of Triple-Negative Breast Cancer and Its Clinical Features at Incidence in Indian Patients With Breast Cancer. JCO Glob Oncol . 2020 Jul

4. Early Breast Cancer

5. Evolution of surgery in Breast Cancer

6. Treatment options Early Breast Cancer (cT1-2 cN0-1)

7. ESMO Guidelines-2024

8. NCCN GUIDELINES

9. NCCN GUIDELINES

10. Evidence in favour of Surgery

11. No difference in OS in NACT vs ACT T size in cm % <2 28 2.1-4 59 >4.1 13 N0 74%

12. No difference in OS in NACT vs ACT T size in mm % CR (%) 1-19 20.2 34.6 20-49 70.5 26.6 ≥50 8.2 35.5 Unknown 1.1 25.4 Luminal type % CR (%) ER+ PR+ 15.0 31.9 ER + PR 3.5 26.6 ER- PR - 18.7 35.5 Unknown 62.8 25.4

13. NACT associated with increased local recurrence

14. PCR rates Types of NACT CR (%) No anthracycline or taxane 18.5 Anthracycline , no taxane 26.0 Anthracycline and taxane 41.0

15. TNBC pCR ( ypT0/ yTis , yN0) 38.5% T stage % T1 10.6 T2 61.7 T3 19.8 T4 1.2 Nodal status % N0 49 N+ 53 Unknown 0.7

16. (T1 (diameter >1.0 cm to 2.0 cm) to T2 (diameter >2.0 cm to 5.0 cm)

17. 77% had tumour size more than 5cm. 88% had node positive disease. I n younger patients (<50yrs) resulted in an 18.5% absolute increase in pCR rates 12.5 % absolute increase in event-free survival 11.2 % absolute increase in overall survival 

18. Improved pCR rates with immune checkpoint inhibitors

19. Trials Regimen pCR T size GeparSixto Weekly pacli + liposomal doxorubicin +/- carboplatin With carbo 53.2% Without carbo 36.9% T1-77% T2-4. 69% N0-78% N+ 58% BrighTNess carboplatin plus veliparib with paclitaxel versus paclitaxel 53 % vs 49 % T1- 10 to 13 % NO- 57 to 60% N1 – 41 to 43 % CALGB40603 (Alliance) trial carboplatin once every 3 weeks or bevacizumab once every 2 weeks added to once per week paclitaxel for 12 weeks followed by ddAC 54% v 41% T1- 49 patients T2-291 CTNeoBC 33.6% Tnbc – 20.3% T1-6.6% T2-61.7% N0-51.9 % N+ 48.1 %

20. OS benefit only in pCR patients Five-year EFS for patients with and without pCR was 86% and 50%, respectively, while 5-year OS for patients with and without pCR was 92% and 58%, respectively.

21. T1a,b tumors have an excellent prognosis without chemotherapy 52 % of the patients were TNBC. Without Chemotherapy- The 5-year DRFS T1a -93 % to 98% T1b - 90% to 96 %.

22. TNBC - histological subtype A Acinic cell carcinoma B Adenoid cystic carcinoma C Metaplastic carcinoma D Low grade Adenosquamous carcinoma E Low grade mucoepidermoid carcinoma F Secretory carcinoma G Tall cell carcinoma H TNBC NOS

23. TNBC with rare histology subtype - no benefit from Chemotherapy NCCN recommends:

24. Thank You

25. Scenario in BBCI Stage NACT NACT REGIMEN SURGERY MRM BCS CT1cN1 4 4 CT2N0 2 2 cT2N1 5 5 2 3 Total patients discussed in JTB with early TNBC for the 1 st half of 2024 – 16