Post-Surgery Treatment Considerations for HER2-Positive Breast Cancer Patients

The appropriateness of postoperative treatment for breast cancer?

1.
The patient has stage I breast cancer (Estrogen receptor: negative / Progesterone receptor: negative / HER2: positive / Ki-67: 60%).
The postoperative treatment recommendation is to undergo six cycles of chemotherapy combined with targeted therapy using the following three medications: a.
Herceptin 270 ml/HR b.
Lipo-Dox 278 ml/2HR c.
Endoxan 295 ml/HR.
Prior to this treatment, the patient underwent an echocardiogram and a CT scan, which revealed several concerning findings (Echocardiogram report: the patient has mild pulmonary valve regurgitation, mild mitral valve insufficiency with mitral valve prolapse, and right ventricular hypertrophy; CT report: the patient has unresolved inflammation in both lungs, linear infiltrates in both lungs, thickening of the interlobular septa, atherosclerosis of the aorta, and calcification of the coronary arteries).
Given this condition, is it still appropriate to proceed with the aforementioned treatment? After the fourth cycle, the patient experienced a significant fever and severe shortness of breath; is it still suitable to continue chemotherapy?

Ms. Huang, 60~69 year old female. Ask Date: 2020/07/23

Dr. Chen Jiaming reply Surgery

If there are concerns regarding the treatment in a clinical situation, it is advisable to discuss them with the attending physician, as online consultation information is insufficient to determine the appropriateness of treatment.
The imaging reports prior to chemotherapy and the clinical changes after the fourth cycle of chemotherapy (which has been at least two months apart) are often difficult to correlate.
Imaging reports are ultimately just textual descriptions, and sometimes certain chronic findings may persist throughout a patient's life.
Clinicians will still consider other clinical signs to make their assessments.

Reply Date: 2020/07/23

More Info

Post-surgery treatment for HER2-positive breast cancer patients is a critical aspect of managing the disease and improving outcomes. In the case presented, the patient has been diagnosed with stage I breast cancer characterized by negative estrogen and progesterone receptors, positive HER2 status, and a high Ki-67 proliferation index of 60%. This profile indicates an aggressive form of breast cancer that is likely to benefit from both chemotherapy and targeted therapy.

Treatment Recommendations
1. Chemotherapy: The recommendation for six cycles of chemotherapy is standard for HER2-positive breast cancer, particularly when the tumor is aggressive (as indicated by the high Ki-67). The chemotherapy regimen mentioned includes:
- Herceptin (trastuzumab): This is a targeted therapy specifically for HER2-positive breast cancer. It works by binding to the HER2 protein on the surface of cancer cells, inhibiting their growth and promoting apoptosis (programmed cell death). Herceptin is typically administered alongside chemotherapy to enhance the effectiveness of the treatment.

- Lipo-Dox (liposomal doxorubicin): This formulation of doxorubicin is designed to reduce side effects while maintaining efficacy against cancer cells. It is particularly useful in treating breast cancer.

- Endoxan (cyclophosphamide): This is a traditional chemotherapy agent that works by interfering with the DNA replication process in cancer cells.

2. Targeted Therapy: The inclusion of Herceptin is crucial for HER2-positive patients, as studies have shown that it can significantly reduce the risk of recurrence and improve overall survival rates.

Considerations for Treatment
Before proceeding with the chemotherapy regimen, it is essential to evaluate the patient's overall health, particularly the cardiovascular status, given the reported heart conditions. The echocardiogram findings of mild pulmonary valve regurgitation, mild mitral valve insufficiency, and right ventricular hypertrophy raise concerns about the patient's ability to tolerate certain chemotherapy agents, especially those that can have cardiotoxic effects, such as doxorubicin.

Monitoring and Adjustments
1. Cardiac Monitoring: Given the patient's pre-existing cardiac conditions, close monitoring of cardiac function is necessary throughout the treatment. This may involve regular echocardiograms to assess any changes in heart function and to ensure that the patient can safely continue with the chemotherapy regimen.

2. Management of Side Effects: The patient has experienced significant side effects after the fourth cycle of chemotherapy, including high fever and severe shortness of breath. These symptoms could indicate a serious reaction to the treatment, such as an infection or an allergic reaction, and warrant immediate medical evaluation. If these symptoms persist or worsen, it may be necessary to pause the chemotherapy and conduct further investigations to determine the underlying cause.

3. Consultation with Specialists: It is advisable for the treating oncologist to collaborate with a cardiologist to assess the risks associated with continuing chemotherapy in light of the patient's cardiac issues. This multidisciplinary approach ensures that the treatment plan is both effective against cancer and safe for the patient's overall health.

Conclusion
In summary, while the proposed treatment plan for HER2-positive breast cancer is appropriate, careful consideration of the patient's cardiac health is paramount. Continuous monitoring and potential adjustments to the treatment regimen may be necessary to balance the efficacy of cancer treatment with the safety and well-being of the patient. Open communication between the patient and the healthcare team is essential to address any concerns and to make informed decisions regarding ongoing treatment.

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