|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 401-402
Only 9 weeks or complete 12 months of adjuvant trastuzumab in Indian early-stage breast cancer patients: Is it the practice-changing approach in a resource-constrained setting?
Chaturbhuj R Agrawal, Kshitiz Domadia, Pankaj Goyal
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
|Date of Submission||08-Mar-2020|
|Date of Decision||09-Mar-2020|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||19-Jun-2020|
Chaturbhuj R Agrawal
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi - 110 085
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agrawal CR, Domadia K, Goyal P. Only 9 weeks or complete 12 months of adjuvant trastuzumab in Indian early-stage breast cancer patients: Is it the practice-changing approach in a resource-constrained setting?. Cancer Res Stat Treat 2020;3:401-2
|How to cite this URL:|
Agrawal CR, Domadia K, Goyal P. Only 9 weeks or complete 12 months of adjuvant trastuzumab in Indian early-stage breast cancer patients: Is it the practice-changing approach in a resource-constrained setting?. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 6];3:401-2. Available from: http://www.crstonline.com/text.asp?2020/3/2/401/287265
We have read with great interest the article by Manuprasad et al., which, to the best of our knowledge, is the largest analysis regarding short-course adjuvant trastuzumab in breast cancer from the Indian subcontinent, and we would like to congratulate the authors for this. To summarize, this was a retrospective analysis of 129 early-stage breast cancer patients who had received only 9 weeks of adjuvant trastuzumab with chemotherapy, and it was concluded that this strategy of short-duration trastuzumab is feasible in a low-resource country like ours with favorable outcomes considering the high treatment cost and minimal benefits.
We agree with the authors that the high cost is the biggest hurdle in administering the entire 12 months of adjuvant trastuzumab, but this was in the past and with the available generic versions of trastuzumab, this issue has been addressed to a large extent. We agree that in the prior study by Adusumilli et al., only one-third of the patients (35.8%) received adjuvant trastuzumab, but this was a retrospective study that recruited patients from January 2007 to December 2013, and the cost of adjuvant trastuzumab quoted was around ₹1,000,000, but, since then, the times have changed, and now, the cost of generic trastuzumab has decreased by approximately 65% (approximately ₹340,000 for 17 vials). The above statistics may not hold true in future, and presently, the drug is more affordable for the majority of patients.
The benefits of adjuvant trastuzumab versus no trastuzumab are well documented, but the optimal duration has always been debated upon. Unfortunately, the available literature as of now is is somewhat contradictory. On the one hand, the PHARE trial  indicated that 6 months of adjuvant trastuzumab therapy was not noninferior to 12 months, whereas on the other hand, the PERSEPHONE trial  showed no compromised efficacy with less cardiotoxicity with the same duration of trastuzumab. However, the patient profile in PERSEPHONE was very favorable, i.e., 59% had node-negative disease and 69% had estrogen receptor (ER)-positive disease. In this trial, the benefits of shortened trastuzumab regimen were limited to subgroups of patients who were ER positive, received anthracyclines as part of their chemotherapy regimen and with sequential trastuzumab, however longer follow-up may unveil further facts. Data are further very limited for the 9-week duration. The FinHer study  primarily compared docetaxel with vinorelbine, however the patients also received 9 weeks of trastuzumab compared with no trastuzumab. The results were numerically similar to 1 year of trastuzumab, but the study was not powered to comment upon statistical significance. The Short-HER trial  again compared 9 weeks versus 1 year of therapy; the noninferiority of 9-week therapy was not proven, but shorter duration decreased cardiac side effects and can be given in those at very low risk of recurrence. A recent meta-analysis from China  again concluded that 1 year of adjuvant treatment has survival benefits and should be preferred whenever feasible, while shorter duration may serve as an alternative for patients with cardiac disease and those with lower recurrence risk.
In this study by Manuprasad et al., the notable drawbacks are its retrospective design, no arm of 3-weekly trastuzumab and only single-arm study with limited follow-up, and lack of timely cardiac evaluations. There remains an unmet need of a randomized controlled trial in the Indian population  before finalizing the 9-week option of trastuzumab as the approved option. At present, complete 12 months of adjuvant trastuzumab continues to be the standard of care, but shorter duration may be considered for the limited patient population having the lowest risk of recurrence or if finances are not available for 12 months of even generic trastuzumab.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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