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HR Positive HER2 Negative Breast Cancer at ASCO 2024

CE / CME

Cancer Conversations on the Expanding Therapeutic Landscape for CDK4/6 Inhibitors in HR-Positive/HER2-Negative Breast Cancer

ABIM MOC: maximum of 1.50 Medical Knowledge MOC points

Physicians: Maximum of 1.50 AMA PRA Category 1 Credits™

Released: June 17, 2024

Expiration: June 16, 2025

Sara A. Hurvitz
Sara A. Hurvitz, MD, FACP
Erica L. Mayer
Erica L. Mayer, MD, MPH
Joyce O'Shaughnessy
Joyce O'Shaughnessy, MD
CME/CE Information

Pretest

Progress
1 2 3
Course Completed
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1.

Presurvey 1: Which of the following could indicate high-risk disease and inform adjuvant therapy decision-making for a patient with newly diagnosed HR+/HER2- EBC?

2.

Patient Case 1: Woman With Grade 2 ILC and 4 Positive Nodes



  • A 58-yr-old woman who is postmenopausal presents with a 5-cm right breast mass with 1 suspicious node

  • Initial breast biopsy reveals ILC, grade 2, with the following biomarkers

    • ER 80%, PgR 30%, HER2- by IHC



  • Fine-needle aspiration of a palpable right axillary lymph node reveals adenocarcinoma of the breast

  • BRCA testing: negative

  • Patient receives neoadjuvant TC x 6 cycles and then undergoes bilateral mastectomy

  • Right mastectomy specimen reveals a 3-cm ILC with minimal chemotherapy effect and 4/15 positive nodes

  • She returns to the clinic now to discuss adjuvant treatment options

Presurvey 2: Which of the following would you select as adjuvant therapy for this patient?

3.

Patient Case 2: Woman With Grade 2 IDC and 1 Positive Node



  • 42-yr-old woman with right breast grade 2 IDC s/p lumpectomy and SLNB

  • 3.2-cm grade 2 IDC 

  • ER 95%, PgR 50%, HER2 1+ by IHC, FISH negative, Ki-67 35%, 1/3 SLN positive for ITCs (pT2pN0i+)

  • BRCA1/2 negative

  • Receives TC x 6, RT, ready to start endocrine therapy

Presurvey 3: Which therapy would you recommend (assuming regulatory approval for all options)?

4.

Patient Case 3: MBC After Adjuvant ET



  • 62-yr-old woman was initially diagnosed with stage IIA ER+/HER2- breast cancer 7 yr ago

  • She underwent surgery, adjuvant TC x 4 chemotherapy, and completed 5 yr of adjuvant letrozole therapy 2 yr ago

  • She presented recently with persistent back pain, for which she has had to take ibuprofen

  • Further imaging disclosed widespread bone lesions consistent with metastatic breast cancer and supraclavicular lymphadenopathy

  • Laboratory testing is normal aside from elevated alkaline phosphatase

  • Node biopsy confirmed metastatic breast cancer, ER+/HER2 1+ 

  • ctDNA evaluation notable for lack of ESR1 or PIK3CA mutations

Presurvey 4: Which first-line systemic therapy would you recommend?

5.

Patient Case 4: Progression From  High-Risk EBC to MBC



  • 57-yr-old postmenopausal woman had history of high-risk node-positive ER+/HER2-  early breast cancer in 2021; she underwent surgery, received adjuvant chemotherapy and adjuvant radiotherapy, and was started on letrozole 

  • She also started adjuvant abemaciclib but did not want additional medication and stopped it in early 2022 after 6 mo 

  • She presents in spring 2024 with gradual fatigue and weight loss; imaging is notable for findings consistent with MBC, with lesions in bone, mediastinal lymph nodes, and 2 liver lesions

  • Liver biopsy confirms MBC: ER 50%, PgR 30%, HER2 1+

  • ctDNA evaluation shows an ESR1 mutation and a PIK3CA mutation

  • Laboratory testing is normal; despite her symptoms, she continues to work full time and walks her dog daily

Presurvey 5: Which first-line systemic therapy would you recommend?

6.

Patient Case 5: Elevated LFT With Ribociclib



  • 55-yr-old woman was recently diagnosed with metastatic ER+/HER2- breast cancer

  • Disease recurrence 2 yr after completing adjuvant endocrine therapy with asymptomatic bone-only disease

  • 4 wk ago, she began receiving first-line letrozole and ribociclib (600 mg daily, 3 wk on, 1 wk off)

  • Laboratory monitoring at C2D1 shows LFTs are now 5x ULN (grade 3 hepatotoxicity); she is otherwise asymptomatic; ECG is stable

Presurvey 6: Which of the following is optimal management for this patient’s grade 3 LFT?

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