Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Will you offer adjuvant abemaciclib to breast cancer patients with high Ki-67 who are unable to receive either neoadjuvant or adjuvant chemotherapy due to comorbidities or who decline chemotherapy?
Chemotherapy was given to the majority of patients on MonarchE because they were high risk at diagnosis. For patients at high risk, I will continue to offer chemotherapy in addition to adding adjuvant abemaciclib to endocrine therapy. For those patients who refuse or in whom adjuvant chemotherapy is...
Does the magnitude of benefit with 2 years of adjuvant abemaciclib outweigh side effects, given that many patients will receive CDK 4/6 inhibitors at breast cancer recurrence, precluding OS benefits?
In terms of balancing benefit in terms of risk reduction of cancer recurrence versus adverse events, this is always an important consideration in introducing a novel therapy. In patients who are at high risk based on the criteria for the trial, namely node positive based on more than 4 nodes or if 1...
How far can you dose reduce abemaciclib for a patient who is having toxicity at starting doses?
I think this is an extremely important question with broad applicability to drug dosing in general, and particularly in the elderly who not uncommonly are both less tolerant and less forgiving of side effects. If drug efficacy is truly maintained over a range of dosing and not just dose related rela...
Would you offer adjuvant abemaciclib plus endocrine therapy for favorable histology ER+/PR+/HER2-negative tumors such as pure tubular, mucinous, cribriform, or papillary that otherwise meet MonarchE trial criteria?
These pure subtypes are rare (<5%) and many pathology studies state that the term should be reserved for cases where at least 90% of the tumor is tubular or mucinous with low grade features to be considered favorable. In one retrospective study for over 100 G1 pure tubulars, only 5% had N1 disease a...
For patients with prior HR+HER2- localized breast cancer currently receiving adjuvant endocrine therapy, is there a time period in which you would no longer recommend adding adjuvant abemaciclib?
This is a great question and I hope we eventually have data to guide us. I also do not know how insurers will handle these types of requests. This high-risk ER+ population has a 10-year risk of distant recurrence between 20 to 40% with continued risk of recurrence over 20 years based on the EBCTCG d...
Would you recommend adjuvant abemaciclib for ER+ HER2 neg inflammatory breast cancer who do not achieve pCR with neoadjuvant chemotherapy?
I would certainly consider it. It would be helpful to have additional information: How many LN were positive at diagnosis? What is Ki-67? Grade--likely grade 3 for inflammatory How much residual disease at surgery? Though none has given definitive answers to assist, these factors could play roles...
Would you give chemotherapy to a post menopausal woman with ER/PR positive HER2 negative breast cancer, T2N1 with 3+ lymph nodes, Ki-67 30% and OncoType RS of 10?
I would not give this postmenopausal woman adjuvant with a recurrence score of 10 based on RxPONDER trial. In that trial women with recurrence scores of 25 or less were randomized to receive chemotherapy + endocrine versus endocrine therapy alone. The Kaplan Meier curves were superimposable. I would...
What adjuvant systemic therapy would you give a patient with pN2 nodal relapse of ER+/HER2- breast cancer now s/p ALND, after initial mastectomy, adjuvant TC, and 5 years of endocrine therapy?
I'll give my thoughts, but appreciate others here as well. I'm assuming this patient is likely now post-menopausal, and also assuming that they had 5 years of endocrine therapy and then relapsed off of adjuvant therapy.I'm guessing the patient did not have radiation as they had a mastectomy and did ...
What factors would you consider when deciding between tamoxifen vs OFS/AI in premenopausal women with early stage HR+ breast cancer?
I think the question is asking when would I recommend tamoxifen alone versus aromatase inhibitor plus medical ovarian suppression with agents like goserelin or leuprolide in a premenopausal breast cancer patient. There are multiple factors to consider. If she has a history of active endometriosis or...
Do you recommend axillary dissection for women with ER+ breast cancer and low risk Oncotype or Mammaprint if single node positive with only 1-2 SLN removed, to ensure <4 nodes positive?
No, I see no need to do dissection in this setting. Unless there is clinical or imaging evidence of gross disease, radiation should adequately control microscopic residual disease in the axilla.