Armando Orlandi, Medical Director at the Agostino Gemelli University Hospital Foundation IRCCS, shared a post on LinkedIn:
“ASCO26 | Early & Adjuvant Breast Cancer Rapid Oral Session — Key Takeaways
Two directions at once: peeling back treatment intensity where outcomes allow, and investing more in survivorship
De-escalating systemic therapy in HER2+
- IRIS-A (#508): adjuvant capecitabine + trastuzumab (no IV chemo) gave 5-yr iDFS 97.9% in stage IA HER2+ (n=187) — a chemo-light option for very small tumors; phase III pending.
- HELEN HER-013 (#509): neoadjuvant nab-paclitaxel + trastuzumab + pyrotinib was non-inferior to TCHP on pCR (63.1% vs 59.2%) — more diarrhea, less anemia.
Revisiting chemo dogmas in HR+/HER2−
- ADAPT + PlanB pooled (LBA515): in high-risk HR+/HER2− eBC, no survival difference by anthracycline use or neoadjuvant vs adjuvant setting; longer docetaxel-based regimens looked favorable. Retrospective, hypothesis-generating.
My take: if even in genomically high-risk luminal disease NAC isn’t superior to adjuvant — and OPTIMA (#500) now shows chemo can be safely omitted even in N2 by ROR score — the message converges: in luminal HER2− disease, NAC chemotherapy should rarely be the default. Operate first, then define the optimal adjuvant systemic strategy, where biology and the surgical specimen inform the decision.
The default in luminal HER2− disease should flip: surgery first, systemic therapy decided afterwards. Neoadjuvant chemo earns its place only when it changes the operation — never as a reflex.
Surgical de-escalation
- SHAVE + SHAVE2 pooled (#513): cavity shave margins halved margin positivity (14% vs 35%) and re-excision (9% vs 24%), but local recurrence and 5-yr DFS/OS were unchanged — only radiotherapy improved DFS.
Survivorship & tolerability
- BETTER-CARE (LBA510): a needs-adapted follow-up model missed its QoL endpoint but cut fatigue, depression (aOR 0.46), cognitive impairment and neurotoxicity.
- MedDiet + walking + vitamin D (#511): no overall recurrence difference, but high adherence in HR+ disease tracked with 76% lower recurrence (HR 0.24) — adherence drives benefit.
- OASIS-4 (#512): elinzanetant improved sleep and menopause QoL across all endocrine-therapy types — non-hormonal relief for vasomotor symptoms.
ADCs moving early
- I-SPY 2.2 (LBA514): neoadjuvant rilvegostomig + T-DXd gave high pCR in immune-positive HER2− disease (HR+immune+ 57% vs 15% goal), letting most responders skip chemo — ILD (11.4%) needs attention.
- DESTINY-Breast05 safety (#516): drug-related ILD was higher with T-DXd than T-DM1, influenced by country and renal function; most ILD/pneumonitis low-grade and reversible.
Bottom line: the field keeps testing how much treatment patients truly need — lighter chemo in HER2+, fewer anthracycline reflexes and a surgery-first logic in luminal disease — while ADCs push into the neoadjuvant space and survivorship earns a bigger seat.”
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