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Navigating Treatment Sequencing in HER2+ Metastatic Breast Cancer: Evidence-Based Approaches - Episode 1

Clinical Scenario I: 52-year-old Woman With Recurrent Metastatic HER2+  Breast Cancer

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Panelists discuss how a 52-year-old elementary school teacher diagnosed with HER2-positive (HER2+) breast cancer achieved pathologic complete response with neoadjuvant therapy but experienced metastasis 18 months after completing treatment, requiring first-line metastatic therapy.

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    Clinical Brief: Treatment Sequencing in HER2+ Metastatic Breast Cancer

    Key Themes:

    • Case Presentation: 52-year-old woman with initially early-stage HER2+ breast cancer (estrogen receptor/progesterone receptor+) who achieved pathologic complete response with neoadjuvant therapy but developed metastatic disease 18 months later
    • Initial Metastatic Treatment: Patient received docetaxel, trastuzumab (Herceptin; H) and pertuzumab (Perjeta; P), followed by maintenance HP with endocrine therapy
    • Disease Progression: After 14 months, disease progressed in liver and bones, leading to consideration of trastuzumab deruxtecan as second-line therapy

    Key Points for Physicians:

    • Despite achieving pathologic complete response, patients with HER2+ disease may still develop metastatic disease
    • Brain MRI at diagnosis of metastatic disease should be considered, especially with widespread disease
    • First-line therapy typically includes taxane with trastuzumab and pertuzumab followed by maintenance therapy

    Notable Insights:

    • The patient’s presentation highlights that achieving pathologic complete response does not guarantee cure
    • The case demonstrates standard sequencing of treatment following current guidelines
    • Consideration of systemic therapy change is appropriate after progression on first-line treatment

    Clinical Significance:

    Treatment sequencing in HER2+ metastatic breast cancer requires careful assessment of disease characteristics, prior treatments, and timing of recurrence, with evidence supporting a shift to trastuzumab deruxtecan upon progression after first-line therapy.

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