Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider using OncoType Dx testing in a patient with breast cancer if nodal evaluation is not performed?
In women who are 65 and older who have clinically negative axilla, there are less node assessments done with BCS, given data showing they do not add very much. If the patient is otherwise a candidate for adjuvant chemotherapy, I do check a genomic expression profile, either OncotypeDX or MammaPrint....
Would you still obtain Ki-67 prior to use of adjuvant abemaciclib in a patient who has otherwise met MonarchE treatment criteria, such as 1-3 positive LNs, grade 3 and/or tumor >5 cm?
In the setting of a patient with residual disease after NAT with an initial grade 3 stage IIIA ER positive breast cancer, I would treat with adjuvant abemaciclib regardless of Ki67 status if the absolute risk of recurrence was high enough. pCR rates after NAT for ER positive breast cancer are low, a...
Would you offer OFS/AI alone or with the addition of chemotherapy in a premenopausal female with ER+/PR+ breast cancer with microscopic LN involvement and an OncoTypeDx score <11?
Oncotype recurrence score (RS) testing provides both prognostic and predictive information. This is a tumor with a low score and has an excellent prognosis, regardless of what treatment is given. Chemotherapy would not be necessary in an endocrine-sensitive tumor such as this.The issue, of course, c...
Do you provide prophylactic anticoagulation with abemaciclib in the adjuvant setting given known thrombosis risk?
I don’t generally recommend prophylactic anticoagulation with abema, either in the adjuvant or metastatic setting. There does appear to be a small, but real, incidence of thrombosis associated with abema, as well as the other CDK 4/6 inhibitors. While this risk is quite uncommon, it is important cer...
How do you decide whether to offer tamoxifen or OFS + AI in premenopausal patients with metastatic ER+ HER2+ breast cancer as your endocrine therapy?
In general, for node-positive premenopausal women, I use AI and OS. For node-negative patients, I generally use tam + OS for oncotypes 16-21 (the group where we saw a 2% benefit from chemo in TAILORx) and AI + OS for oncotypes 21-25 (where we saw a 7% benefit from chemo in TAILORx). It seems from SO...
What would be your treatment approach in a premenopausal BRCA2+ patient with cT2N0 grade 2-3, ER negative, PR variably positive (30%; staining weak to high), HER2 negative breast cancer?
Since weakly hormone-positive, HER2-negative breast cancer behaves more similarly to triple-negative breast cancer than strongly hormone receptor-positive breast cancer (Poterala et al., PMID 35676188), I would approach this patient similarly to patients with stage 2 triple-negative breast cancer. I...
Would you send Oncotype for pre-menopausal women with HR+, HER2(-) breast cancer with a small tumor (pT1b) and micrometastatic LN involvement or recommend adjuvant chemotherapy without sending Oncotype?
That is a very good question, especially considering that the RxPONDER trial showed benefit from chemotherapy in pre-menopausal women with 1-3 lymph nodes involved by breast cancer. However, this trial excluded patients who had micro-metastatic disease as the only nodal involvement, so we can't appl...
Would you avoid chemotherapy in a postmenopausal woman age >65 with T3 HR+/HER2 negative with Oncotype DX < 25?
Prior to RxPONDER, we had to speculate: https://www.themednet.org/question/8265. We have more data now. RxPONDER included T3 patients (252 or 5% were T3) (Supplementary Appendix). So my answer mirrors that of the Oncotype website: "Postmenopausal women with 1 to 3 positive nodes and Recurrence Score...
How do you manage endocrine therapy for a perimenopausal woman with ER+ breast CA?
In lower risk patients to whom I would not routinely give chemotherapy - stage I-IIA, with a low or low-intermediate risk Oncotype score - I start tamoxifen and switch to an aromatase inhibitor (except in very low risk patients in whom the benefit of switching would be negligible) when they are clin...
What adjuvant endocrine therapy would you recommend for patients who have undergone prior gastrectomy?
This is challenging with no good evidence based recommendations to my knowledge. In the past, with a patient post gastrectomy, I have elected to do tamoxifen therapy and checked absorption level by checking endoxifen level after a few weeks on therapy.