Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with metastatic HR positive breast cancer presenting with spinal cord compression but no visceral metastases, what is your recommended first line systemic therapy?
If it is a de-novo metastatic breast cancer, I would start systemic therapy with AI/fulvestrant or CDk4-6/fulvestrant combo. I have a similar patient who has had a long clinical course with only recurrent spinal metastasis leading to cord compression. No visceral metastasis. Monitor with spine MRI p...
How do you treat leptomeningeal disease in metastatic HR+ HER2- breast cancer?
Survival after a diagnosis of leptomeningeal metastasis (LM) remains poor. Radiation therapy remains a primary therapy for breast cancer LM. Intrathecal therapy has resulted in limited efficacy and is associated with significant toxicity. Limited data regarding the efficacy of systemic therapies in ...
Would you consider a treatment holiday in a patient with HR+ oligometastatic breast cancer who is in a prolonged remission?
Obviously, we have little data to guide our approach here. However, I would feel a bit uncomfortable holding the patient's AI but would consider it in certain situations, such as the patient having toxicities that are difficult to tolerate. In that situation, I would consider an alternative endocrin...
Do you prefer CDK 4/6 inhibitor or PARP inhibitor as first line treatment in a patient with HR+/HER2 neg relapsed/metastatic BRCA positive breast cancer who had previous adjuvant chemotherapy and developed metastatic recurrence while on AI?
PARP inhibitors haven’t been compared head-to-head with CDK4/6 inhibitors in combination with endocrine therapy, but I would start with the CDK4/6 inhibitor + fulvestrant and save the PARP inhibitor for second line. If the patient has brain metastases, I would use the PARP inhibitor instead. If I ha...
Would you consider AI alone over CDK4/6 inhibitor combinations in older patients with breast cancer considering the subgroup analyses from MONALEESA-2 suggest less benefit in patients over 65?
In MONALEESA-2, 295 patients (44%) were ≥ 65 years of age, 150 were randomized to ribociclib + letrozole; and 145 received placebo + letrozole. 370 patients were <65 years of age, 184 were randomized to the ribociclib group, and 186 to the placebo group. The baseline characteristics were balanced be...
How do you approach systemic treatment for intracranial only brain metastases for ER positive, PR negative, HER2 negative breast cancer after stereotactic radiosurgery for brain metastases with negative PET imaging?
Assuming the patient's treatment history doesn't suggest resistance, I would treat the patient with endocrine therapy plus abemaciclib along with regular brain MRI monitoring.
For patients with metastatic HER2-null breast cancer, do you offer trastuzumab deruxtecan based on the DAISY trial results?
DAISY trial was a small trial and the outcome was hypothesis-generating rather than practice-changing. With that said, I offer trastuzumab deruxtecan to patients with metastatic breast cancer even if HER2 IHC on biopsy of metastatic disease was 0 but historically, their primary tumor tested at least...
Would you start fulvestrant plus CDK4/6 inhibitors in a patient with ESR1 mutation with metastatic breast cancer on liquid biopsy in a first-line setting?
Since the presence of ESR1 mutation is associated with a lack of benefit from aromatase inhibitors, I tend to start patients who have evidence of this mutation on fulvestrant in combination with a CDK 4/6 inhibitor (typically ribociclib). ESR1 mutation found on circulating tumor DNA suggests that a ...
How would you treat a patient with symptomatic and rapidly progressing metastatic HR+, HER2 low breast cancer with PIK3CA WT, ESR1 mutated, TMB high after progression on CDK 4/6 inhibitor, a taxane, and T-DXd?
With disease progressing on increasing number of systemic therapy lines, the likelihood of having a response diminishes. In the absence of an impending organ crisis, one could consider fulvestrant with alpelisib, elacestrant, or pembrolizumab. However, if the patient is facing an impending organ fai...
What is your preferred first line therapy for metastatic HR+ inflammatory breast cancer?
Data for non-IBC metastatic HR+ breast cancer has demonstrated excellent efficacy of endocrine-based therapy in the 1st line setting allowing delay of chemotherapy until later lines. However, IBC behaves very differently than non-IBC and tends to be higher grade with more endocrine resistance. Given...