A new diagnosis of breast cancer presents the patient with serious clinical decisions to make. An early-stage breast cancer treatment in the precision medicine era, as you mentioned, evolves all the time. New targeted therapies for early-stage breast cancer treatment go through many clinical trials. What is new in customizing the cancer treatment for patients with early breast cancer?

I believe the most important data with immune checkpoint inhibitors. Recently, we had the opportunity to listen to the data of KEYNOTE-522. That is a prospective randomized clinical trial. It evaluated the role of pembrolizumab in the early triple-negative breast cancer. The addition of pembrolizumab to standard chemotherapy improved the rate of pathological complete response. But most importantly, pembrolizumab improved the rate of invasive disease-free survival, with the trend in positivity in overall survival. So using immune checkpoint inhibitors, both in the neoadjuvant and in the adjuvant setting for early triple-negative breast cancer, may potentially improve overall survival in this patient population.

In what situations patients with early breast cancer might avoid chemotherapy altogether? Is there such a chemotherapy-free breast cancer treatment scenario available now? Will it be available shortly? For some patients?

This is a very good question. We have several genomic tests actually, like Recurrence Score or like Mammaprint. They can really select those patients who can avoid chemotherapy. Let us specifically go into the details. You may be a postmenopausal woman with estrogen receptor-positive and HER2/neu-negative breast cancer. You perform a test Oncotype DX Recurrence Score test. If you have an intermediate risk score or a low-risk score, you can for sure avoid chemotherapy even if you have cancer involvement in one to three lymph nodes. So this is a large population of breast cancer patients who, in the early breast cancer setting, can really avoid chemotherapy.

Is there anybody in the pre-menopausal women patients who might avoid the chemotherapy altogether?

This is a very good question. For premenopausal patients with breast cancer, we don't have exactly the same results of the postmenopausal breast cancer setting. But I am quite sure that some breast cancer patients with low recurrence scores may for sure avoid chemotherapy. They can receive endocrine therapy alone for breast cancer.

There is more and more use of extensive genomic sequencing. For example, Tempus xT panel, Foundation Medicine panels are available. How often do you recommend to your patients to have more extensive genetic testing in the setting of a new breast cancer diagnosis?

In the context of metastatic metastatic breast cancer, the use of those genomic panels should be reserved for patients who are candidates to participate in clinical trials. So, in my opinion, in a comprehensive cancer center like mine, the European Institute of Oncology of Milano, we should offer NGS for all metastatic breast cancer patients who are potential candidates for clinical trials.