ASO Author Reflections: ‘Right-sizing’ the Treatment Approach for Small HER2 Positive Breast Cancers
Carolin Mueller, Rahul Rangan, Megan Kruse, Zahraa Al-Hilli
Abstract
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Taxonomy
TopicsHER2/EGFR in Cancer Research · Advanced Breast Cancer Therapies · Breast Cancer Treatment Studies
Past
The overall benefit of intensive systemic therapy for small HER2-positive breast cancer remains debatable, given the low risk of both distant and local recurrence. In recent years, de-escalated treatment strategies have demonstrated excellent outcomes. For example, the APT trial reported a 98.7% 3-year disease-free survival rate and a 94.3% 10-year overall survival rate using only adjuvant weekly paclitaxel and trastuzumab, followed by trastuzumab monotherapy in stage I patients (T < 3 cm, N0).^1^ In addition, the WSG-ADAPT-HER2+/HR- trial evaluated 12 weeks of neoadjuvant trastuzumab and pertuzumab, with or without paclitaxel, in patients with HER2-positive, hormone receptor-negative breast cancer.^2^ Among those who achieved a pathological complete response (pCR), omitting further chemotherapy did not negatively affect invasive disease-free survival.^2^ These findings have sparked growing interest in whether all patients truly benefit from aggressive systemic therapy, or if less intensive treatment could offer similar efficacy with reduced toxicity.
Present
Current guidelines recommend treatment with neoadjuvant therapy (NAT) primarily for node-positive or high-risk node-negative patients, while stage I disease is generally managed with upfront surgery.^3^ This approach is echoed in the article, “trends in the management of small HER2 positive breast cancers,” which highlights treatment patterns among patients with cT1N0 breast cancer.^4^ The use of NAT rose from 7.1% in 2018 to a peak of 30.2% in 2021, before declining to 9.1% in 2022. This fluctuation reflects the evolution in clinical practice influenced by key trial results that emphasize tailored treatment strategies for small HER2-positive tumors.^1,2^ Furthermore, adjuvant therapy over the study period tended to be less aggressive, potentially improving treatment adherence and completion rates. In addition, nodal upstaging after primary surgery in clinically node-negative patients occurred in 14.1% of cases, suggesting a limited benefit from treatment with NAT compared with surgery first.
Future
Our study supports primary surgery rather than neoadjuvant therapy for the treatment of small HER2-positive breast cancers. Further studies are needed to continue to identify patients who can safely undergo less intensive systemic treatment while maintaining similar oncologic outcomes and reducing treatment-related toxicities.