Editor's Note: On July 14, to mark the 40th anniversary of Yunnan Cancer Hospital, the "8th Yunling Breast Cancer Summit Forum," hosted by the Yunnan Anti-Cancer Association and the Chinese Medical Education Association, was held in Kunming. The event gathered cutting-edge advances in breast cancer from domestic and international experts. Dr. Qianjun Chen from Guangdong Provincial Hospital of Traditional Chinese Medicine delivered a keynote report on "Consensus and Controversies in Anti-HER2 Therapy for HER2-Positive Breast Cancer." "Oncology Frontier" interviewed Professor Chen on site to share insights on the consensus and controversies in anti-HER2 therapy for HER2-positive breast cancer, guiding multidisciplinary collaboration to optimize patient management strategies, extend patient survival, and improve quality of life.01
Oncology Frontier: At this conference, you presented on “Consensus and Controversies in Anti-HER2 Therapy for HER2-Positive Breast Cancer.” Could you discuss the current controversies in the treatment of HER2-positive breast cancer?
Dr. Qianjun Chen: New evidence from evidence-based medicine is continuously emerging in breast cancer, resolving some clinical issues but also challenging existing treatment strategies and causing more controversies. This makes the new evidence difficult to meet clinical practice needs, requiring more research or thought to resolve the disputes. Clinical research often lags behind clinical practice. This phenomenon is simply because expanding the boundaries of medical knowledge inevitably leads to more unknowns, which is necessary for medical progress.
Early HER2-positive breast cancer is no exception. For instance, the ExteNET study established that high-risk patients need neratinib reinforcement after one year of trastuzumab monotherapy. However, in current clinical practice, high-risk patients often receive dual-target therapy with trastuzumab and pertuzumab (HP) instead of trastuzumab monotherapy. This raises a new issue: how to interpret the application of the ExteNET study in the context of modern clinical practice? After one year of HP dual-target adjuvant therapy, is neratinib reinforcement still needed, and if so, which patients need it? These are pressing questions that need answers.
Neoadjuvant therapy in early HER2-positive breast cancer has become a consensus. If lymph node-negative patients achieve pathological complete response (pCR) after HP dual-target neoadjuvant therapy, it remains unknown and controversial whether subsequent treatment should be downgraded to trastuzumab monotherapy. Currently, the St. Gallen consensus suggests downgrading, but this opinion is inconsistent with domestic guidelines, warranting further thought. For non-pCR patients after neoadjuvant therapy, the previous domestic guidelines recommended corresponding treatments based on MP grading, which had some discrepancies. Due to changes in health insurance policies, there is now a consensus on this contentious issue in China. However, new controversies remain, such as whether small molecule tyrosine kinase inhibitor (TKI) neratinib can still be used after adjuvant T-DM1 therapy and how it should be used, lacking supporting evidence. These are just some of the many controversies in early HER2-positive breast cancer.
For advanced HER2-positive breast cancer, the HP dual-target therapy is the standard first-line treatment. However, new evidence supports combining large molecule monoclonal antibodies and small molecule TKIs as a first-line treatment. How to distinguish the practical populations for these two regimens in clinical practice? In second-line treatment, the new ADC drug T-DXd has become the new standard. How should the previous “old second-line standard regimens” like T-DM1 and TKIs be arranged? These are issues that clinicians need to discuss and resolve urgently.
Overall, the increase in controversial issues in HER2-positive breast cancer is a positive development. Addressing these issues will inevitably generate new controversies, reflecting medical progress. Therefore, I hope clinicians use their wisdom to resolve these controversies through more clinical research and strive to provide better services for patients.
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Oncology Frontier: How should we conduct multidisciplinary collaboration to address the current controversies in HER2-positive breast cancer?
Dr. Qianjun Chen: Multidisciplinary collaboration is crucial in the diagnosis and treatment of breast cancer, and HER2-positive breast cancer is no exception. For example, post-neoadjuvant therapy management of pCR and non-pCR involves many controversial issues. The key to discussing these issues is a strong pathology team for standardized and accurate assessment and differentiation of pCR and non-pCR. Additionally, the imaging team’s monitoring of tumor regression patterns post-neoadjuvant therapy greatly assists surgical procedures and pathological assessments. Moreover, breast medical oncologists and cardio-oncologists also play very important roles. Therefore, a strong multidisciplinary team (MDT) in a center greatly benefits the resolution of controversial issues in breast cancer and the optimization of overall treatment strategies.
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Oncology Frontier: Breast cancer is gradually moving towards chronic disease management, making patient education and psychological support very important. How should hospitals and doctors effectively support patients?
Dr. Qianjun Chen: The relationship between doctors and patients is one of mutual trust and support. Breast cancer has generally moved towards chronic disease management, even the previously highly invasive and poor prognosis HER2-positive breast cancer has become relatively mild due to treatments like monotherapy, dual-target therapy, and ADCs. In this context, educating patients about the progress in breast cancer treatment and the benefits it brings is very important, enhancing patients’ confidence in overcoming HER2-positive breast cancer.
Besides medical treatment education, surgical education also needs to be strengthened. Many patients still believe that “removal is safer” for breast cancer, a view from decades ago but still common in society. I want to share that surgical treatment has made great strides. Clinical practices now include breast conservation, oncoplastic breast conservation, prosthetic reconstruction, and autologous tissue reconstruction. Many institutions, including ours, pursue scarless reconstruction using endoscopic and robotic techniques. Breast surgery today is vastly different from the past, offering effective, safe tumor treatment while preserving or reconstructing the breast. Educating patients on these advances will increase their confidence in medical progress.
In terms of psychological support, we need professional psychological teams involved in managing breast cancer patients. The word “cancer” often brings significant psychological stress to patients. Despite our educational efforts, some patients still experience depression, anxiety, and insomnia due to psychological pressure. Clinically, we aim not only to keep patients alive but also to ensure they live well. Professional psychological teams and traditional Chinese medicine (TCM) emotional therapies can effectively intervene and improve patients’ quality of life. As a TCM practitioner, I believe traditional Chinese practices like Gua Sha, acupuncture, and herbal treatments can enhance physical and psychological health. Our next goal is to precisely apply these treatments to patients, achieving integrated TCM and Western medicine for comprehensive, precise, lifelong management of breast cancer.
In summary, comprehensive management using integrated TCM and Western medicine methods supports the treatment journey of breast cancer patients, helping them live longer and better. This is my lifelong pursuit as a breast cancer doctor.
Dr. Qianjun Chen
- MD, Chief Physician, Doctoral Supervisor, Postdoctoral Advisor
- Vice President of Guangdong Provincial Hospital of Traditional Chinese Medicine
- President of Zhuhai Hospital of Guangdong Provincial Hospital of Traditional Chinese Medicine, President of the Breast Disease Specialty Hospital
- Academic Leader in Traditional Chinese Surgical Science at Guangzhou University of Chinese Medicine
- Chairman of the Breast Disease Branch, Chinese Association of Traditional Chinese Medicine
- Member of the Breast Cancer Expert Committee, Chinese Society of Clinical Oncology (CSCO)
- Member of the Breast Cancer Professional Committee, Chinese Anti-Cancer Association
- Editorial Board Member of “Journal of Guangzhou University of Traditional Chinese Medicine”
- Editorial Board Member of “China Cancer Prevention and Treatment Journal”
- Review Expert for “Gland Surgery”
