Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you use platinum therapy in BRCA1 mutated patients with ER/PR positive disease receiving neoadjuvant chemotherapy?
In the absence of any data (of which I am aware) of benefit from adding a platinum analog to neoadjuvant chemotherapy in BRCA1-mutated patients with ER-positive/HER2-negative cancers (other than those with minimal ER expression, whom I treat as I do patients with triple-negative cancers, with the ad...
Can you use Oncotype for determining adjuvant therapy in a young, premenopausal woman with multifocal HR+ breast cancer s/p mastectomy with 2 positive lymph nodes?
There are no data yet that I am aware of (retrospective or prospective) for the use of Oncotype 21 gene assay to make treatment decisions in premenopausal women with node positive, estrogen receptor positive early stage breast cancer. The prospective RxPONDER trial will hopefully provide data on the...
How do you approach recurrent, localized HR+, HER2- breast cancer in a patient who has progressed on exemestane (and previously on letrozole and tamoxifen)?
If the tumor is not resectable, I would use fulvestrant and a CDK inhibitor; but if the ER/PR expression is low, I might consider pre-operative chemotherapy using a standard adjuvant chemotherapy regimen—most likely AC-T. If the tumor is resectable (or has been resected), then I would use adjuvant c...
How do you approach recommending tamoxifen in a premenopausal woman with Li Fraumeni syndrome and early stage low risk ER+ breast cancer?
The risk of uterine sarcoma is 17 per 100,000 patients per year on tamoxifen which is higher than the average population, i.e., 2 per 100,000 patients per year. The lifetime risk of soft tissue sarcoma in Li Fraumeni Syndrome (LFS) female patients is about 15%. In a series of 64 LFS breast cancer pa...
Are pre-menopausal women on tamoxifen at risk for endometrial cancer?
Analysis of endometrial cancer rates in the NSABP P1 trial in women under age 50, demonstrated a relative risk of 1.42 (0.55-3.81) for tamoxifen that was not statistically significant. Per 1000 women, the rates were 0.82 for placebo and 1.16 for tamoxifen. (Fisher et al., PMID 16288118)
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
In light of RxPonder results for postmenopausal women with early stage node positive HR+HER2- breast cancer, when is there a role for full axillary LN dissection to confirm degree of nodal involvement and when would sentinel LN evaluation be sufficient?
I don’t think the RxPonder study changes surgical management. Still follow Z0011 paradigm.
Do you need to wait for estradiol and FSH levels to normalize before you can switch from tamoxifen to an AI for a pre-menopausal woman with ER+ breast cancer?
Since tamoxifen can also affect hormone levels, it is prudent to hold tamoxifen for a month before checking hormone levels. In this case, it is reasonable to stop tamoxifen due to endometrial thickening. One could consider checking hormone levels after a month of stopping tamoxifen and if they are i...
Would you use OncoType Dx to guide adjuvant therapy recommendations in the context of locally recurrent, node-negative, ER+ breast cancer previously treated with endocrine therapy alone?
Assuming that 1.) the recurrence is in ipsilateral breast tissue post-radiation therapy, 2.) the patient is on adjuvant hormone therapy, and 3.) the pathologist concurs that this is not a new primary, we could approach this problem on multiple fronts.1.) Does the tumor harbor an ESR1 mutation? Altho...
How do you plan to use adjuvant denosumab in patients with hormone positive breast cancer given the survival advantage seen in the ABCSG-18 trial?
Both adjuvant denosumab at 60 mg SQ every 6 months and adjuvant zoledronic acid at 4 mg IV every 6 months are reasonable options to consider as part of adjuvant treatment in post-menopausal women and both have prospective data to show statistically significant but very small improvements in disease ...