The current role of anthracyclines in early breast cancer

In this insightful discussion between Dr Eline Naert, a medical oncologist from Ghent University Hospital and Prof Evandro de Azambuja, medical oncologist from the Institut Bordet, Brussels, the focus revolves around the evolving role of anthracyclines in early breast cancer. The discourse unfolds as a critical analysis of their applicability across different subtypes.

For luminal breast cancer, the historical use of anthracyclines faces a re-evaluation. Recent trials,  indicate comparable outcomes between anthracycline and non-anthracycline regimens for patients with high genomic scores or high mamma print. With a concern for cardiotoxicity, the prevailing sentiment leans towards non-anthracycline chemotherapy, particularly in cases with one to three positive lymph nodes.

Shifting the spotlight to triple-negative breast cancer, a consensus emerges in favour of anthracycline inclusion, given the absence of contraindications. The neoadjuvant Keynote 522 regimen, intertwining paclitaxel, carboplatin, anthracycline, and pembrolizumab, provides a clear directive. However, in the adjuvant setting, the decision to employ anthracycline is contingent on tumour size, with T1c tumours still meriting consideration.

HER2-positive breast cancer echoes the luminal paradigm, emphasising anti-HER2 treatment over chemotherapy. The neoadjuvant setting largely avoids anthracycline use, opting for a regimen with docetaxel, carboplatinum, trastuzumab, and, if necessary, pertuzumab. In the adjuvant setting, tumour size dictates the approach, with T1abc tumours favouring non-anthracycline regimens.

The incorporation of anthracyclines prompts a vigilant stance against cardiotoxicity. Collaborative efforts with cardiologists, guided by risk assessments and adherence to guidelines, become pivotal. Preventive measures, such as beta-blockers, ACE inhibitors, or statins, are considered for those at intermediate or high risk.

The discourse culminates in a contemplation of managing ER-low patients, constituting 1-9% ER-positive tumour cells. The prevailing trend leans towards treating them in line with triple-negative breast cancer, especially for larger tumours, utilising chemotherapy with pembrolizumab. Anthracycline use in this subset is nuanced, contingent on the extent of disease and patient characteristics.