Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you discontinue anti-hormonal therapy if a high-risk ER+ HER2- localized breast cancer patient develops blood clots on anti-hormonal therapy?
Tamoxifen has been associated with an increased risk for venous thromboembolic events, but there does not appear to be any increased risk with the aromatase inhibitors in the placebo controlled studies. These include MA.17, MA.17R in the extended endocrine therapy setting and MAP.3 and IBISII in the...
Is there a role for the neoadjuvant use of CDK 4/6 inhibitors with endocrine therapy in patients with well differentiated and/or invasive lobular histology who desire breast conservation?
The role of neoadjuvant CDK4/6 inhibitors has been explored in multiple phase 2 trials including the neoMONARCH and PALLET trials. The data from these studies suggest that abemaciclib and palbociclib are active in ER+ early stage breast cancers by causing a more complete arrest of tumor cell prolife...
How would you treat a postmenopausal woman with recurrent, localized ER+,HER2- breast cancer to the contralateral breast while on AI?
Assuming this a new primary, you would treat it like another primary breast cancer with breast surgery +/- radiation. If clinically appropriate you would send genomic testing (i.e., Oncotype or Mammoprint) to make decisions about adjuvant chemotherapy. The contralateral breast cancer (CBC) recurrenc...
What factors influence whether you order OncotypeDx in HR+ node negative ILC?
If there is differential ER/PR expression or other high risk features such as pleomorphic features or high grade.
Would you use neoadjuvant CDK4/6 inhibitor and AI in HR+ breast cancer based upon the randomized phase II CORALLEEN trial?
I would not use CDK inhibitors in the neoadjuvant setting.
Would you consider adjuvant capecitabine in a premenopausal patient with HR-positive inflammatory breast cancer who had residual disease after neoadjuvant chemotherapy?
Yes, I would consider adjuvant capecitabine for a patient with residual invasive disease after standard neoadjuvant chemotherapy (NAC) for HR+ inflammatory breast cancer. Given the uncertainties about the absolute benefit in recurrence and mortality in this specific situation, I would discuss this w...
How would you approach adjuvant therapy for a young post-menopausal woman with a grade 3 pT1a (5mm) node negative ER+/HER2- invasive ductal carcinoma?
There is no data from the prospective trials to support genomic testing in T1a tumors. TAILORx did not enroll T1a tumors. A G3 tumor under 1cm is clinically low risk so Mammaprint would not have clinical utility either. Since NCCN doesn't recommend chemotherapy in this scenario, I would not test.
How would you council a woman in her 50s with Stage I HR+/HER2- breast cancer with a high risk Mammaprint but intermediate OncotypeDx regarding adjuvant chemotherapy?
This is a challenging question to address without more details. The first question is why were two different assays run on the tumor? Also, in the context of the TAILORx data which demonstrated a lack of benefit from chemotherapy for postmenopausal women with Oncotype DX recurrence scores 25 or less...
In cases in which Oncotype DX test is not available, how do you decide which patients with HR+ and Her2- breast cancer are candidates for adjuvant chemotherapy?
If OncotypeDx is not available for an ER+ Her2- primary breast cancer: In general, there are two main components to the 21 gene assay: proliferative thrust and estrogenic signaling. Thus tumors that have strong staining for ER tend to be driven by estrogenic signaling. This is especially true if th...
How does age factor into your planning whether to give a high risk pre-menopausal patient with breast cancer ovarian function suppression?
Generally, my age cutoff is 50, but it depends on the patient’s documented menopausal status prior to chemotherapy. If the patient is perimenopausal, then I initiate ovarian suppression plus aromatase inhibitor and check estradiol and FSH every 12 months. When she is clearly post-menopausal, then I ...