Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How strict are you about adhering to the eligibility criteria required for entry onto the OlympiA trial in considering a year of adjuvant olaparib as adjuvant therapy for BRCA mutated, node positive, ER positive breast cancer?
When considering PARP inhibitors or CDK4/6 inhibitors in the adjuvant setting, we follow the criteria used for the trials. This is because the trials dictated what is now in the guidelines and the guidelines dictate what insurance will cover.
What alternate neo-adjuvant backbone chemotherapy would you recommend in a patient with ER+ HER2+ clinical stage II breast CA with severe pan-colitis following a cycle of TCHP with docetaxel?
I would switch to weekly paclitaxel and carboplatin with trastuzumab only, but might retry pertuzumab if the patient gets through 6 weeks without recurrent diarrhea. This is actually my preferred version of TCHP (including the pertuzumab), which I find to be better tolerated than the every-3-week do...
What is your cut off on ER percent positivity to treat breast cancer as functional triple negative cancer?
I usually use less than 10% ER positivity as the cut off. In this case, I would treat as if the tumor is TNBC.
Do you modify your choice of systemic therapy for localized early stage ER+/PR+ HER2- breast if Mammaprint shows basal subtype?
It would make me want to recheck the ER/PR IHC through another lab to make sure it is truly positive. There are some ER positive tumors (especially low expressors) that have basal transcriptional profiles suggesting a lack of estrogen pathway signaling. If the ER is truly positive and it is >= 10% o...
How do you interpret the EBCTCG meta-analysis analyzing the magnitude of benefit of anthracyclines in early stage ER+ breast cancer?
The appreciation of studies testing the specific benefit of adding or substituting anthracyclines as adjuvant therapy for early stage breast cancer requires a historical overview (so my apologies for a very long response….). Several of the earlier trials comparing non-anthracycline therapies (primar...
Would you give adjuvant endocrine therapy to a premenopausal woman with early stage node positive breast cancer that was ER negative, PR positive (60%) and HER2 positive?
The first thing I would do in this case is have the block retested for ER staining preferably at a different lab. There have been multiple studies published in the past that have shown ER negative PR positive tumors (particularly strong PR staining like this one) frequently end up being ER+ on retes...
Would you consider adjuvant chemotherapy for a patient with HR+/HER2- breast cancer, luminal type A on Mammaprint, after knowing that the patient had a poor response to neoadjuvant endocrine therapy?
I'm going to assume this is an older patient who is postmenopausal, as current guidelines from ASCO state that neoadjuvant endocrine therapy (NET) should not be offered to premenopausal women.My first question is: which specimen was tested? There was a nice poster looking at gene changes and Mammapr...
How would you approach a patient with ER+,HER2- T4N0 breast cancer with chest wall involvement?
In a patient with locally advanced ER positive HER2 negative breast cancer, requiring neoadjuvant therapy, I would use third generation chemotherapy such as AC followed by paclitaxel (often in a dose dense fashion), as long as there are no contraindication to anthracycline based regimen. This EBCTCG...
How do you approach a post-menopausal female with early stage ER+,HER2+ breast cancer s/p lumpectomy with invasive ductal histology and lymph node involvement with invasive lobular histology?
The discrepancy between histology in the lymph node and breast is concerning for occult invasive lobular carcinoma in the breast. It would be a good idea to obtain second opinion in pathology. If pathology is confirmed, breast MRI could help identify invasive lobular cancer that may not be easily de...
How would you approach a patient with T3 HR+,HER2- breast cancer who had no clinical improvement after ddAC?
This is one of those questions where I wish I had a tiny bit more information about the decision-making behind electing NAC. For instance, was this breast cancer grade 3, with a high Ki-67 and ER 25% PR ngtv? Or was this patient a very borderline candidate for breast-conservation and motivated enoug...