Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant olaparib to a male patient with HR+, HER2- T2N0 breast cancer with a BRCA2 germline mutation following mastectomy who is not a candidate for adjuvant chemotherapy?
Will offer brief thoughts but welcome others as well. First, I think it would be helpful to know what risk stratification has been done to decide the patient should be offered chemotherapy and not just endocrine therapy. Also, it would be useful to know why they are not a candidate for chemotherapy ...
How would you approach adjuvant systemic therapy in a HR+ premenopausal patient over the age of 50?
Since you are citing the RxPONDER study, I assume this is a premenopausal woman over age 50 with N1 node positive disease.In the RxPONDER study, for premenopausal women, the 5-year HR for iDFS with chemo was 0.6. Same for distant DFS. But the benefit was mainly seen in premenopausal women under 50. ...
How would you manage a HR+/HER2+ breast cancer patient with no response during neoadjuvant TCHP?
A few thoughts: Although we know that patients with ER+/HER2+ are less likely to respond to neoadjuvant chemo and dual HER2-targeted therapy than those who are ER-/HER2+, I would confirm that the patient is truly HER2+; if the diagnosis was made by IHC, would send FISH or CISH. If the patient has ...
In which scenarios do you use vaginal estrogen in patients with history of HR positive breast cancer?
A recent study (McVicker et al., PMID 37917089) supports the likely safety of vaginal estrogens in breast cancer survivors. Limitations of this study are that it primarily included lower-risk individuals with stage I-II disease and women 50+. In addition, the level of data is limited by the retrospe...
When do you recommend preoperative chemotherapy or hormonal therapy for ER+ breast cancer?
While trying to downstage the patient's tumor to make her a better candidate for breast-conserving surgery or to improve her cosmetic outcome is the primary reason why I administer neoadjuvant therapy in patients with HR+/HER2- breast cancers, there are occasionally other reasons, including delaying...
Do you think about CDK4/6 inhibitor selection differently in a patient with de novo rather than recurrent metastatic disease?
Not really. Would recommend endocrine therapy with CDK 4/6i for both patients with de novo metastatic disease and those with disease recurrence. The type of endocrine therapy might vary though - would consider Fulvestrant as endocrine therapy partner for a patient who has disease recurrence on adjuv...
How long would you continue trastuzumab and pertuzumab in a patient with ER+ HER2+ breast cancer with initially osseous involvement treated with ACT-HP and is now in CR by PET for >2 years?
All physicians who treat metastatic HER2 breast cancer eventually have patients who appear to have been "cured" of their metastatic disease with available agents. This question crops up from time to time, wondering if there is some measure of time or test we can use to determine when it would be rea...
How do you manage HR+HER2 negative ILC metastatic recurrence in a post-menopausal woman with extensive GI involvement complicated by a small bowel obstruction?
I think the answer to this question depends on a few factors. The management and outcome of patients with malignant bowel obstruction is described quite well by Tuca et al., PMID 22904637. The type of therapy I try would be influenced by their overall condition. Certainly, I would consider this an "...
Would you consider de-escalating treatment to endocrine therapy alone in a patient with prolonged NED on CDK 4/6 inhibitor + endocrine therapy?
Be good to know more specifics about her breast cancer history, whether this is administered as a first line in an endocrine sensitive setting versus not. If her history is in line with endocrine sensitivity, I think it would be reasonable to de-escalate her treatment to endocrine therapy alone and ...
How would you manage subsequent treatment for a patient with metastatic ER+HER2- breast cancer that develops pneumonitis on a CDK4/6 inhibitor but had an excellent response to therapy?
One of our fellows and I conducted a lit search on this topic several months ago, and then again (briefly) today. There is not much literature to support evidence-based decision making, as the 3 available CDK4/6 inhibitors (palbociclib, abemacicilib, and ribociclib) all have pneumonitis as a reporte...