Small Triple-Negative and HER2-Positive Early Breast Cancer: Upfront Surgery or Neoadjuvant Chemotherapy?

Area of Science:

• Oncology
• Breast Cancer Research
• Clinical Therapeutics

Background:

• Breast cancer (BC) treatment involves surgery, radiotherapy, chemotherapy, endocrine therapy, and targeted therapies.
• High-risk BC, including triple-negative breast cancer (TNBC) and HER2-positive BC with involved lymph nodes, typically receives neoadjuvant chemotherapy (NAC).
• Recent advancements in immunotherapy for TNBC and targeted therapies for HER2-positive BC have improved survival for high-risk patients.

Purpose of the Study:

• To review and discuss therapeutic strategies for early-stage triple-negative breast cancer (TNBC) and HER2-positive breast cancer (BC) without suspicious or involved axillary lymph nodes.
• To delineate treatment decisions between upfront surgery and neoadjuvant chemotherapy (NAC) for specific early-stage BC subtypes.
• To explore the utility of prognostic tools, such as tumor-infiltrating lymphocyte (TIL) levels, in guiding treatment selection.

Main Methods:

• This is a narrative review synthesizing current evidence and clinical guidelines.
• Discussion focuses on treatment approaches for clinically staged T1a-b N0 M0 (cT1a-b cN0 usN0) and T1c N0 M0 (cT1c cN0 usN0) TNBC and HER2-positive early breast cancer.
• Analysis considers pathological staging (pT1b pN0, pT1a pN0, pT1c pN0) and factors influencing treatment decisions, including lymphovascular invasion, tumor size, grade, patient age, and comorbidities.

Main Results:

• Upfront surgery is recommended for cT1a-b cN0 TNBC and HER2-positive BC, with adjuvant therapy considered based on pathological findings (pT1b pN0).
• For pT1a TNBC, no adjuvant chemotherapy is recommended; for pT1c TNBC and HER2-positive BC, adjuvant therapy is generally advised.
• Neoadjuvant chemotherapy (NAC) is recommended for cT2 or cN+ TNBC and HER2-positive BC, and can be strongly considered for cT1c cN0 cases based on specific clinicopathological features and prognostic indicators.

Conclusions:

• Treatment decisions for early-stage TNBC and HER2-positive BC without lymph node involvement require careful consideration of tumor characteristics and prognostic factors.
• Prognostic tools like TIL levels, TNBCDX, and HER2DX can aid in personalizing treatment strategies, including the choice between upfront surgery and NAC.
• Adjuvant therapy decisions should be individualized based on pathological results and patient-specific factors to optimize outcomes.