Questions discussed in this category
Are there any subgroups that would still benefit from RNI?
How do you stage and evaluate premenopausal patients with >= cN1 ER+ PR+ HER2- breast cancer prior to surgery to avoid this pitfall?
Would you offer adjuvant Pembrolizumab combined with Capecitabine?
Does the low ER+ or metaplastic histology affect your recommendations?
Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy.
Is there compelling reason to start PMRT prior...
What would be your approach to a patient who went straight to surgery due to HR+ biopsy, but found to be triple negative on surgical pathology?
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
PFS curves appear similar between the AKT-altered vs overall study population in the trial publication. Is there any additional information available ...
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
Would you be more inclined to use it if a patient had early discontinuation of pembrolizumab due to IRAE?
Patient underwent an axillary dissection with ITCs in 1/23 nodes.
Oncotype score in this case was 14.
Add OFS with endocrine therapy plus Taxane-HP combo? What taxane is preferred?
Although grade 3 toxicity rates were low, ~10.5% experience some degree of ILD, are there strategies to reduce risk before treatment starts?
Are ther...
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
How would you counsel the patient given the drug interactions present?
For example, women of southeast Asian descent.
Any pitfalls to be aware of?
Would clinical stage or nodal status affect your decision?
How would you approach treatment with systemic therapy, surgery, and radiation if there is evidence of little treatment response, tumor growth, and ne...
As immune checkpoint inhibitors have expanded into the neoadjuvant breast cancer setting, severe and unexpected autoimmune toxicities may cause delays...
What factors would influence your decision?
Given the results of DESTINY-Breast03, and T-DXd's labeled indication in second-line, what is now the role of TDM1 in the treatment armamentarium of H...
Since HR low-positive, HER2 neg tumors behave aggressively similar to TNBC, does the degree of HR positivity factor into your decision-making?
Does the type of breast cancer factor into your decision making?
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
Would you no longer trust the prognostic value of Mammaprint knowing the poor response to endocrine therapy?
What is your treatment algorithm?
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
As expected triple negative.
Is there data on the long-term effects of abemaciclib on future fertility and pregnancy after its discontinuation?
Does the patient's desire for futu...
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
In the setting of the recent TailorRx data, would these patients be considered more high risk?
Would you still treat with neoadjuvant KEYNOTE-522?
For a patient with high risk disease and a severe enough reaction that additional taxane-based therapy is contraindicated, do you consider alternate c...
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
Would you recommend aiming for the postmenopausal range as per the lab reference range or do you have a specific goal?
Does the presence of other cardiac risk factors change your recommendation?
Initial path was T1cN0, and recurrence shows 2/21 ALN involved with ENE, what would you recommend for therapy?
Would you give neoadjuvant chemo or hormonal therapy or go with surgery first? What chemotherapy would you use?
Patient with stage IV ER+PR+Her2- breast cancer progressed after CDK4/6 inhibitor+AI and then on Elacestrant. Guardant 360 showed ESR1 mutation and PI...
In MONALEESA-2, it appears ~22% of those in the ribcociclib group received a subsequent CDK4/6 inhibitor. What was the rationale and could this have i...
Are there other systemic therapy considerations to help achieve sufficient CNS control?
Given OlympiA trial with olaparib benefit for gBRCA+ patients?What are barriers that you foresee? In your practice who performs mutation testing and w...
Would you offer adjuvant radiation therapy if pCR is confirmed?
Group 3 being ratio < 2, copy # >6, and IHC 2+
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
If a patient had a CPS-EG of 2 after neoadjuvant therapy, would you offer that patient olaparib even though she wouldn't have met entry criteria? If t...
Role of capivasertib vs SERD? What factors help you decide?
How does it affect your calculation of risk stratification?
Do you give first-line CDK 4/6 inhibitors with Tamoxifen or Aromatase Inhibitor (+/- GnRH analog)?
Should these patients have a different threshold for utilizing a CDK4/6 inhibitor in the front line metastatic or as part of adjuvant therapy, or SERD...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
Do you feel differently about using these in patients with a history of HR-negative breast cancer?
Would you start with endocrine therapy + CDK 4/6 inhibitor or a chemotherapy based regimen?
If so, in what situations?
RIGHT Choice trial presented at SABCS 2022
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
How does this change for patients with elevated bilirubin?
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
How does data from PADA-1 and EMERALD trials impact your decision-making?
Her gynecologist wants her on hormone replacement therapy.
For example, a patient has had multiple dose reductions for neutropenia and required an admission for infection while on palbociclib. Would you switch...
The patient previously received endocrine therapy alone and in combination with CDK 4/6 inhibitor. She does not have any targetable mutations on NGS. ...
Do you take PR percent into account?
What data may support the routine escalation of endocrine therapy? Should HER2 therapy be prioritized instead?
Would you treat with 1st line ET + CDK4/6 inhibitor if the patient is only low or moderately ER positive?
Would you consider OFS this far out from diagnosis and treatment in a young patient with high grade IDC was treated during pregnancy with neoadjuvant ...
How do you reconcile the apparent benefit in all patients in this group as opposed to the differential effects in premenopausal HR+ node-negative pati...
Are you more worried about QT prolongation in this subset of patients?
What type of adjuvant chemotherapy would you offer? Would clinically positive lymph nodes or residual disease at the time of surgery change your decis...
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
Would you consider doing this in patients with adverse features such as grade 3 or PR negative status?
Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?
Would you biopsy a metastatic site?
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
MONARCHE added an amendment to their protocol to exclude inflammatory breast cancer so they technically would not qualify for the trial though it's ha...
If yes, how do you assess the tumor response and how frequently while on neoadjuvant chemoimmunotherapy?
Patient is pre-menopausal and has cT3cN1, grade 2, ER positive, Her 2 negative IDC. Metastatic disease to axillary LNs was biopsy-proven. Patient was ...
Would you consider offering ovarian suppression?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
Is deferring chemotherapy based on low oncotype acceptable in setting of recurrence?
Would you recommend using a different AI, Tam...
Would you recommend using chemotherapy based on RxPonder regardless of Oncotype score in a premenopausal patient? Or would you hold chemotherapy since...
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
Is there absolute LVEF threshold you would not use HER2 targeted therapies?
Would you consider using endocrine therapy, pembrolizumab, capecitabine, or CDK 4/6 inhibitor?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
Had mastectomy resulting in ypT1cN1a. Post menopausal female with good PS.
If so, under what circumstances?
If NGS was positive would you treat with HER2 directed therapy? How, if at all, would you incorporate T-DXd into this treatment paradigm?
She achieved PCR with NAC with TCHP and is now on adjuvant HP.
In which scenarios would you consider a parp inhibitor as the first line treatment of choice?
Tumor 3 cm, grade 2 with Ki-67 25%
Please specify how your institution is allocating resources now or will be soon.
How do you reconcile these findings with the ABC trials?
(Assuming they meet MonarchE criteria)
For example, if the patient is in year 2, 3, 4, or 5 of adjuvant endocrine therapy versus 9 months out, would ...
Is there a role for KEYNOTE-522 since ER + metaplastic breast cancer have similar behavior to triple negative metaplastic breast cancer?
What is your approach to try to persuade her that photons would be a better option?
If yes, where in sequence would you use it?
Received neoadjuvant ddAC/T followed by adjuvant capecitabine for residual disease and found to have metastatic pulmonary nodules within months of sur...
Does your approach differ across the HER2 IHC spectrum?
Do you use a q4 week or q12 week formulation? If you use both in your practice, what factors into your decision making for either one?
How strongly would you recommend it for a grade 1, < 1 cm DCIS?
The surgeons at our institution are asking for repeat markers but I am not aware of any data or guidelines to support this.
MonarchE trial criteria includes "patients with four or more positive nodes, or one to three nodes and either tumor size ≥ 5 cm, histologic grade 3...
Assuming aromatase inhibitor is not an option due to severe osteoporosis or if it is a man with breast cancer.
Is there any role for AI + OS? What duration of therapy do you recommend?
Fertility preservation already complete with embryo cryopreservation
She had been initially treated with neoadjuvant AC-T followed by BCS and RT with high burden residual disease in the breast and lymph nodes.
The results presented by Sudeep Gupta (from the Tata Memorial Breast Group at 2022 San Antonio Breast Cancer Symposium #GS5-01) showed no benefit (pCR...
If so, which patient population would you use this in?
Markers from surgical path showed ER0PR0 HER2 2+ and positive via FISH in 5% of total tumor population.
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
Since both pregnancy and cancer are risk factors for VTE, is there data to guide when or if we should prophylactically anticoagulate? If so, what shou...
Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...
The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...
Is there a subset of patients for which you consider one regimen over the other (i.e. AC-THP v.TCHP)? If using an anthracycline regimen, do you u...
With studies showing non inferiority to zoledronic acid q 3 months in support of bone metastatic disease, would you consider extrapolating this data a...
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
How do you compare their efficacy overall?
Would you obtain baseline PFT on all patients or only selected high risk patients? Would you repeat PFTs regularly or only if clinically symptomatic?&...
Given strong TDXd efficacy in these patients is there a role to use it earlier than 2nd line?
How does prior Her2-directed and/or taxane therapy...
While rare, these patients were excluded from all frontline CDK4/6 inhibitor trials. Is there any data on the efficacy of ribociclib in the CNS or abi...
Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?
Results with fulvestrant and letrozole backbone in MONALEESA and MONARCH trials seem comparable, but PALOMA data is somewhat mixed. How do these trial...
Subgroup analyses in MONALEESA-2 suggest more benefit in de novo treatment naive patients, which is in contrast to MONARCH-3 data presented at ESMO 20...
What subsequent adjuvant therapy would you recommend?
Would you recommend adjuvant chemotherapy for pT4 disease regardless of Oncotype score?
Would you offer it to a woman with a history of a provoked DVT?
If a patient previously received taxane-based chemotherapy for the initial cancer, is additional chemotherapy recommended or can HER2-directed and hor...
Is the marginal advantage of AC/T in 1-3 node positive outweighed by toxicity such as risk of cardiotoxicity and leukemia, regardless of RS?
Can you use 50 mg BID if intolerant to 150 mg and 100 mg dosing? Any tips for side effect management to help patients stay on full duration?
MonarchE shows statistically significant improvement in IDFS and DRFS, but the magnitude of absolute benefit is modest (3-year IDFS and DRFS rates = 5...
Some payors prefer leuprolide acetate injectable suspension (eligard) for ovarian suppression. This is not the preparation that was used in SOFT/Text ...
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
Assuming chemotherapy is indicated because of the Oncotype score.
Would you give anthracycline based regimen in a patient with stage III TNBC?
Majority of patients on MonarchE received neoadjuvant/adjuvant chemo.
Does the availability of abemaciclib impact your decision to offer chemo ...
Patient had estradiol level checked by her gynecologist due to recent irregular bleeding. Estradiol level was markedly elevated on initial testing (90...
Patient is young. Bilirubin normalizes when tucatinib is held, but again increases to grade 2 when it is restarted. Evaluation for hemolysis was negat...
Do you look into their stage/risk to decide? Since patients can experience bone loss after stopping denosumab, how do you plan to discontinue?
How reliable is somatic testing to detect an underlying germline predisposition?
What steps should be taken when switching premenopausal women from tamoxifen to AI? In this case, the change is due to newly discovered endometrial th...
For example, if the primary breast tumor was HER2 IHC 1+, but a metastatic site was HER2 IHC 0, would you still recommend using T-DXd?
Will you chang...
Is there evidence that T-DXd crosses the blood-brain barrier?
Prior studies have shown that there can be significant variation between grading pathologists as to which samples are defined as HER2 IHC +1 versus HE...
Patient is a post-menopausal woman with 4 lymph node mets that was strongly ER+/PR+, HER2-negative invasive ductal carcinoma with a high Ki-67 w...
Would you use a different endocrine therapy treatment? Would you use indicators other than Oncotype to guide the need for chemotherapy?
Specifically, how do you consider T-DXd use in setting of other antibody-drug conjugates (e.g. sacituzumab vedotin)? Are there any special considerati...
Do you prophylactically start all patients on B12, B-complex, and/or omega-3? If so, what dose? What about ice mittens and booties?
If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...
- monarchE included <1% Stage IA and < 5% patients with no chemotherapy.Ex: 64 yo, ER/PR 95%, Ki67 20%, cT1c N0 but pT1c N1a at lumpectomy/SLN b...
For example, are you more likely to incorporate T-DXd earlier in sequence for 2+ vs 1+?
Is there any justification to change our approach in HER2-zer...
Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...
In patients with prior perioperative immunotherapy with early relapse, would re-introduction of immunotherapy be reasonable with high TMB?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
At initial diagnosis she had T1cN0 disease treated with lumpectomy and SLNB followed by 12 weeks of paclitaxel with 1 year of trastuzumab.
Definitions for "high risk" differ by whether patients receive neoadjuvant chemo and across other contemporary studies. Does the change in AJCC stagin...
Do you perceive a difference between somatic vs germline BRCA mutations?
What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...
Would you consider definitive local therapy (surgery, radiation?) if she achieved a good response to initial systemic therapy?
Would you include a CDK4/6 inhibitor knowing the patient doesn't meet criteria of monarchE trial but still is Stage IV?
Would you ever consider using these in sequence?
Would you consider omitting treatment if small tumor and early stage? Or would you use tamoxifen?
Patient was initially ER positive, HER2 positive. Currently she is on letrozole. Recurrence is ER/PR negative and HER2 positive and developed almost 2...
OlympiA trial did not include her2+ breast cancer.
The OncotypeDx score was 51 in this scenario.
ER low being 1-9% (<10%), PR 20%
Young patient, germline BRCA carrier with cT1cN0 to ypT2N0 disease after docetaxel/ cyclophosphamide x 4.
Would you proceed with KEYNOTE 522 regimen and add anti-HER2 targeted therapy adjuvantly?
What would you offer a premenopausal woman with clinical T2N1 ER positive breast cancer for adjuvant therapy after she achieves a pathologic complete ...
What do you do if LFTs are elevated after one dose of neoadjuvant TCHP (highest ALT >13 times upper limit of normal, normal bilirubin) with prior n...
Would you consider the discontinuation of either anti-HER2 agent or both?
I have a patient in her 60s with CHEK2 mutation, diagnosed with bilateral breast cancer. Lumpectomy showed b/l tumors <10mm both ER/PR+, HER2-, but...
Should these cancers be treated like hormone positive breast cancer or triple negative breast cancer?
She is pre menopausal with cT1c grade 2 disease...
What scenarios would you do second neoadjuvant treatment vs surgery?
If said patient was known to be gBRCA mutated, would you use neoadjuvant chemotherapy to enable adjuvant olaparib for those that did not have a pCR? &...
Ref: Geyer et al, Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and hi...
How much of the benefit of adjuvant chemotherapy do you expect to be due to ovarian function suppression due to the chemotherapy?
Is dose modification of docetaxel necessary with Gilbert's when giving TCHP?
Which agents would you select and for how long would you treat them?
Patient is young and reoccurrence is one year after initial diagnosis of T1cN0 ER/PR positive, HER2-negative breast cancer treated with mastectomy, bu...
In subset analyses of OlympiA there seems to be smaller magnitude of benefit among HR+ patients. In your opinion, should adjuvant olabarib be offered ...
ER 95%
HR+ = ER 34%, PR 0%
RCB2 = no nodal involvement
Would you restart hormonal therapy in a patient with a new diagnosis of LCIS 2 years after they have completed 5 yrs of AI for stage 1A IDC in the oth...
Patient underwent mastectomy for DCIS in the setting of previous lumpectomy and adjuvant radiation for the invasive breast cancer.
Are there contraindications to drugs like oxaliplatin or abraxane?
Does chronicity or severity of the patient's underlying symptoms play a role in yo...
The patient is intolerant to trastuzumab deruxtecan. In which clinical settings would you consider reintroduction of TDM1?
How would you proceed given that cT1c didn't meet the study criteria?
Currently on C2 of doxorubicin/cylophosphomide/pembro. Would you expedite surgery?
Would you continue pembrolizumab? Would you introduce olaparib? If using both, how would you sequence?
Should this be sent on initial biopsy or on surgical pathology? What if an initially high risk patient has good risk findings post-operatively?What ha...
Assume normal cardiac function and no obvious co-morbidities. No anthracycline previously due to age alone. The patient’s BRCA status is unknown...
For instance, the foci found were pN1mi (0.5 mm) deposit in 1st SNL (1/13 LN) and mpT1mi (8 foci). Would you consider single or dual anti-HER2 blockad...
Is there any utility in monitoring serum tamoxifen levels?
For instance, ER/PR >1% but <10% and Ki67 >50%
Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...
Patient is ypT2N1
Patient has already received neo/adjuvant treatment with AC, paclitaxel, capecitabine, docetaxel, and carboplatin.
Would you consider neoadjuvant or adjuvant treatment and if so, which therapies? Patient initially had pT2N0 disease and recurrent disease is also ER+...
Patient previously received neoadjuvant ddAC-T with residual disease at surgery, followed by adjuvant capecitabine which was completed 2 months prior ...
Does not meet Olympia trial indication
In high-risk, node-positive HR+ Her-2 neg breast cancer patients who received neoadjuvant chemotherapy with residual disease, would you give capecitab...
How do you manage low libido in women with breast cancer on endocrine therapy? Other than managing vaginal dryness/dyspareunia, if just a desire/libid...
How would you manage endocrine therapy 7 years after the original ER+/PR+/HER2- IDC, while on adjuvant tamoxifen/OFS develops a contralateral ER+/PR+/...
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
Are there factors to explain why MonarchE was a positive study and PALLAS was not?
High-risk criteria meaning >4 positive nodes and Ki67 >20%
In a patient with a history of VTE (now off anticoagulants), is it safe to administer fulvestrant?
Given arguments exist between the FDA and ASCO, where do you stand?
Given sacituzumab is an antibody drug conjugate of the active metabolite of irinotecan
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
Grade 2 DCIS, post mastectomy with negative margins, sentinel nodes negative
How and when do you plan to perform HER2 testing in patients with NSCLC?
Many of the patients on ASCENT trial were heavily pre-treated and require growth factors. With the day 1,8 treatment cycle, is there a way to minimize...
How does trastuzumab deruxtecan compare to other HER2 targeted strategies?
BRCA mutant, ER/PR positive and HER2 positive T2N0M0 breast cancer diagnosed 5 years ago, treated with bilateral mastectomy, BSO, 1 year of adjuvant a...
For patients with hormone negative breast cancer and HER2 positive only by copy number, do you give TDM1 for residual disease or capecitabine?
No oncotype was sent on the original breast cancer.
Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use?
Do you feel the dosing used in...
Given seemingly improved efficacy in ASCENT patients who had less prior treatment, would you consider use after only one prior agent rather than two? ...
Are there specific patient cohorts in whom you will more preferentially use sacituzumab govitecan?
Can data from ASCENT be applied to patients with C...
This situation can feel uncomfortable. Would this feel safer if patient is s/p mastectomy and had TNBC?
Largest invasive focus is 0.4mm
Are there differences in outcome among the BRCA mutated subgroup, or others?
To what degree do you factor in patient preference when choosing among available treatments? Are there features of each regimen that you emphasize in ...
For example, does a higher recurrence score influence your choice of TC versus AC-T? Or your choice to add ovarian suppression to a premenopausa...
CNS recurrence occurred within two years of prior neoadjuvant therapy
If blood counts are sustained, do you continue or delay?
In which situations would you consider this a reasonable treatment option?
NSABP B51 and B52 specifically prohibit this.
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
Genes such as ATM, CHEK2, PALB2, RAD51C/D, BRIP1 seem to show some potential increased risk of ovarian cancer. Should these patients under prophylacti...
What about a higher penetrance PV such as PALB2?
See JCO OGR 8/2021 by @Mark E. Robson discussing management of non-BRCA pathogenic va...
In a scenario where patient's other clinical/familial risk does not sufficiently qualify them?
See JCO OGR 8/2021 by @Mark E. Robson discussing manag...
Specifically do we know by how much each intervention reduces the risk of developing MBC or increase breast cancer specific as well as overall surviva...
The patient is treatment naïve and asymptomatic. She also has disease in the body (bone and liver metastases).
The patient initially received definitive therapy with AC-T and RT to the breast as well as RT to a solitary bone lesion. She has been on AI for the l...
The patient has extensive liver metastases and a high bilirubin. She has not received any prior systemic therapy in the metastatic setting.
The patient has an intact uterus and has failed all available AI therapies due to multiple intolerances.
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Is there data that it actually helps?
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
Patient was on tamoxifen when progression occurred; unable to tolerate adjuvant AI.
How would this affect adjuvant radiation plan in breast conservation therapy patients and mastectomy patients?
Will you incorporate carboplatin into the backbone as it was done in the KEYNOTE trial?
Patient had an initial tumor response to TCHP, but still had significant residual disease present, including positive lymph nodes and residual breast ...
Do you have a specific age cutoff?
The patient was started on chemoimmunotherapy 3 years ago. Recent scans show small treated brain metastases (s/p RT several years ago) and no disease ...
Presuming that work-up for cardioembolic sources is negative, how would you proceed?
Patient with T2N1 disease and isolated liver metastases. Axilla and liver completely responded to chemo + IO, but limited residual breast enhancement ...
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
No sentinel lymph node biopsy was performed
How would the use of Oncotype guide your management in the neoadjuvant setting?
Based on pCR and EFS data from KEYNOTE 522 and recent FDA approval?
Given that olaparib was given within 12 weeks of completion of standard adjuvant therapy on the trial, will you still offer it to patients outside tha...
What adjuvant therapies would you recommend?
The patient was diagnosed with Ewing’s Sarcoma at the age of 10 and completed 6 cycles of vincristine, ifosfamide, etoposide, adriamycin 75 mg/m...
In patients who have completed all adjuvant therapy. Similar test to what is available for stage 2 and 3 colon cancer patients by Natera.
Do any studies support this rationale? Does the presence of a somatic vs germline BRCA mutation impact your decision?
Patient is on fulvestrant+CDK 4/6 inhibitor and with NED for 5 years. In which cases would you consider stopping CDK 4/6 inhibitor?
How would your management differ in pre- and post-menopausal females?
Would your approach differ if patient is premenopausal or postmenopausal?
Do you discuss patient visits and associated costs when making this decision?
We usually recommend copper IUDs, but that's not feasible in all women.
<40y/o female w/ initial biopsy showing G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 copies/nucleus.)...
Healthy 67 y/o woman, 1.5cm tumor, grade 3
Is there an age cutoff below which you would offer adjuvant chemotherapy regardless of Oncotype results?
(Example: A 35 y/o woman with T2N0, ER+, sen...
Patient was given ddAC + T
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
Would you use trastuzumab/pertuzumab, trastuzumab followed by neratinib, or another strategy?
Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?
Would you choose to incorporate HER2-targeting agents, chemotherapy, endocrine therapy, or a mix of these?
The GeparSixto, CALGB 40603, and more recently Prospero support doing it; however, it is not currently endorsed by NCCN and the latter Prospero s...
How would your plan differ if the patient could eventually receive mastectomy once co-morbidities improve?
Masuda et al., NEJM 2017
i.e. 1/1 node with ECE
Current guidelines for breast cancer do not recommend periodic staging scans in absence of clinical indications.
What tumor or patient characteristics lead you to consider the use of neoadjuvant hormonal therapy without chemotherapy?
Would you recommend the patient stop testosterone upon this new diagnosis? If the patient is not amenable to stopping, would you incorporate an AI in ...
How do you decide on resumption or change of therapy?
How would you approach chemoprevention if tamoxifen is
Are there particular patient characteristics (e.g. age, ER%, Ki67, grade) that make you more likely to choose neoadjuvant endocrine therapy?
Would a pCR to neoadjuvant chemotherapy change your management? (ER <5%, PR <5%)
Do features such as nodal involvement, Ki-67, degree of ER positivity, etc. change your management? Would you use any gene expression assays to help y...
Would you prefer TCHP over TCH? Would you consider adding an anthracycline?
How would you approach additional systemic therapy? Would the clinical stage of the cancer affect your management?
If no anthracycline, what alternative regimen would you consider?
Is adjuvant radiation and/or adjuvant chemotherapy indicated?
Is there any safety data to proceed with TKIs/TDM-1 or to proceed as standard with THP?
For patients who remain NED for years, when would you feel it's appropriate to hold therapy?
What would you offer if the patient is not a candidate for cytotoxic therapy?
Would you consider an Oncotype or Mammaprint? Would your management change if the patient had 1-3 positive LNs on SLNBx (as opposed to ALND)?
The woman was on on a GnRH agonist + AI due to her premenopausal status at diagnosis and now wants to know if she continues to need the GnRH agonist.&...
Would your decision for anthracycline change if the patient were elderly?
Would you send Oncotype during chemotherapy if not sent already? Would you stop adjuvant chemotherapy if a prior Oncotype was 25 or less?
Patient has progressed through prior lines of endocrine therapy.
For patients with low risk, early stage, HR+/HER2- breast cancer who initiated endocrine therapy in order to delay their surgery due to the COVID 19 e...
What is your specific therapy choice and duration?
Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?
I know that many advocate using vaginal estrogen in this situation. Most of the studies of vaginal estrogen in this situation have been small an...
Would you consider gene profiling to determine need for chemotherapy?
Knowing the differential effect seen with menopausal status in RxPONDER, would you avoid chemotherapy or still offer chemotherapy, given that only 15....
Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...
How would you balance the competing risks of these two diagnoses in her treatment?
Patient had a clinical T2N0 cancer at diagnosis, completed 6 cycles TCHP, and had 0.2mm residual disease with 80% cellularity, negative sentinel node.
Do you have any experience with intra-pericardial chemotherapy administration, and if so, in what cases?
Referring to a high risk patient with cT3N1 disease and ypT2N0 disease following neoadjuvant chemotherapy.
Any difference in recommendations if the patient was asymptomatic from her metastatic ER+ disease? (eg bone mets)
How do clinical risk and Mammaprint/Oncotype scores affect your decision?
For example, will you recommend a certain vaccination timing in relationship to their treatment? Any concerns for reduced immune response or risks of ...
Or the converse: changing to IV formulation after starting on subcutaneous pertuzumab/trastuzumab?
Conversely, is there any situation where you would prefer the IV over the subcutaneous formulation?
ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.
Is there a distinction between these tumors and patients with breast cancer with neuroendocrine features?
Given that trials excluded patients with low ER, PR for this approach.
Given the data from KEYNOTE-522, would you try to incorporate chemotherapy in the treatment regimen?
What schedule do you use?
Does tumor size impact your recommendation? High grade? Young patient age?
Would it affect your decision whether original primary tumor and treatment was hormone positive or negative?
2 populations of cells with 95% negative by FISH (ratio 1.07) and 5% positive by FISH (ratio 10)
Do you consider placing an Ommaya for IT chemo with methotrexate or cytarabine? Knowing that leptomeningeal carcinomatosis carries such...
Based on MINDACT update from 2020, a 5% difference in DMFS for patients 50 years or younger was noted, favoring treatment with chemotherapy (93.6%; 95...
What considerations do you take for post-lumpectomy radiation and endocrine therapy?
The trial included only a small percentage of these patients.
Does lymph node positivity change your management?
Would you consider ALND and /or XRT to axilla?
Options:
1) ddAC-T- surgery- adjuvant capecitabine if residual disease
2) weekly taxol/carbo x 12 followed by dd AC x 4
3) Keynote 522- pembro/taxo...
Patient case is triple positive inflammatory breast cancer
Are there any studies that compare them?
How would your treatment change given pCR rates are reportedly much lower in triple positive patients?
Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy.
Initial treatment with Taxane-Trastuzumab-Pertuzumab with then maintenance with the two anti-HER2 agents and and an aromatase inhibitor. Would you bio...
Patient is on anti-hormonal agent (exemestane) with anti-HER 2 agents (trastuzumab and pertuzumab)
She had already completed ddAC and two cycles of paclitaxel before the reaction.
For example: do you use docetaxel + cyclophosphamide (TC) x4 and what is the evidence for using such a regimen
surgically confirmed node negative disease
Recent EBCTCG meta-analysis published in Lancet 4/2023. https://doi.org/10.1016/S0140-6736(23)00285-4
Do you repeat the loading dose of trastuzumab?
Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...
How has your practice been impacted by the ECOG 2108 (Khan et al. ASCO 2020 Abst LBA2)? Are there sites or distribution of disease that prompt you to ...
Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.
BRCA status unknown currently
Given the changing landscape of treatment, some patients may have already received capecitabine previously. Would this impact your treatment rec...
Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?
Would your answer change if the new lesion is ALH/ADH?
Would you consider use of immunotherapy with checking PDL1? What chemotherapy agents would you consider along with mastectomy/radiation?
What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...
Interest in approach for elderly population especially
Would you consider an anthracycline based substitution vs changing to nab-paclitaxel or a combination with platinum agent?
Would you choose a platinum based agent? Other chemotherapy combinations?
Chemotherapy - Carbo/Gem (2nd line). PDL1 and BRCA negative.
Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...
Would you recommend additional cytotoxic chemotherapy and/or switch her anti-Her therapy to T-DM1?
How do you counsel regarding uterine sarcoma risk?
What timeframe would you suggest to stop breastfeeding? From affected breast or both breasts?
Especially if HER2 negative on pathological specimen
Are there specific considerations you/your tumor board take into account?
Asymptomatic brain progression despite CNS surgery and SRS x2 over the past 2 years.
Progression was observed only in the breast and required palliative mastectomy (T4b TNBC)
She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?
Patient completed adjuvant AC-T 8 months prior to recurrence. BRCA negative, foundation medicine NGS pending.
PD-L1 is low and she has residual neuropathy from neoadjuvant paclitaxel.
For example- do you have experience using a LHRH agonist along with tamoxifen?
While the KATHERINE trial for HER2+ used path staging, CREATE-X for TNBC with capecitabine used the Japanese Breast Cancer Society response criteria. ...
Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.
Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?
In cases where patient received 6 cycles of THP and 1 year of HP
Patient received adjuvant chemotherapy and anti-Her2 therapy 3 years ago.
If yes, would you offer tamoxifen or ovarian suppression plus AI?
Received adjuvant HER2 directed therapy 3 years ago.
< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.
Would you consider still immunotherapy even if aggressive disease vs single agent chemotherapy?
For instance, patients with ATM mutations
If so, please describe your experience and dosing.
Does the SYSUCC-001 trial presented at ASCO 2020 change your practice?
If the cancer was also HER2+, would that influence your decision?
This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...
Patient previously received neoadjuvant carboplatin, anthracycline and taxane regimen and is BRCA negative.
How would this change if the patient had metastatic HR+,HER2- breast cancer and now has symptomatic pancytopenia secondary to BM involvement after TCH...
She has received 4 cycles of AC with no clinical response and is now pending completion with Taxol.
Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?
T1a - 2mm; N1 - 1 ipsilateral lymph node measured 6mm
Oncotype says too small to test and NGS says too few cancer cells to determine status.
What chemotherapy regimen would you recommend?
How does gBRCA status impact your decision?
Would your choice vary based on the patient's gender?
Would the recommendation differ based on HR+ vs. TNBC vs HER2+ classification?
Would you recommend against immediate breast reconstruction?
Would you consider delaying chemotherapy and proceeding only with endocrine for now?
Initially treated with anastrozole, current treatment is with fulvestrant.
Personally, my practice is to guide patients directly to surgery or to do neoadjuvant chemotherapy rather than to do neoadjuvant endocrine therapy, bu...
For example, if you had a triple positive breast cancer found on breast biopsy and repeat ER/PR/HER2 testing at the time of surgical resection showed ...
Would your practice vary based on hormone receptor or Her2 status?
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
Would you incorporate platinum into your treatment or enroll in an adjuvant IO trial?
No primary identified in the contralateral breast. No distant metastasis identified.
Do you send multiple Oncotype testing for each sample in a multifocal or multicentric breast cancer?
Tumor size and grade meet criteria for oncotype testing in all foci.
IHC: ER 70%; PR 70%
OncotypeDx: ER - Negative; PR - Positive
Patient received anthracycline and paclitaxel for HR+ breast cancer in the past.
Do you proceed with Paclitaxel or go to surgery instead?
ie, not a classic NTRK3-ETV6 fusion.The patient has progressed through CDk4/6 inhibitors and intolerant of alpelisib, and does not want chemotherapy.&...
She has no other site of disease progression and has been on an aromatase inhibitor (progressed in the CNS while on a study with adjuvant abemaciclib)...
The APT trial reported excellent DFS, OS and RFI for tumors <=3cm but few were smaller T2s (2-3 cm) and few were >70 years old.
Stage T1bN1mic
Assuming the patient is not a candidate for SRS
This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.
Pre-treatment estradiol: <5
Estradiol after 1 yr: 35
For example, if a patient had testosterone pellets injected, perhaps making endocrine therapy less efficacious, would that sway you to use chemo?
Being that this is a favorable histology would you use Oncotype Dx to help decide on neoadjuvant chemotherapy? Would you recommend neoadjuvant endocri...
https://www.ncbi.nlm.nih.gov/pubmed/31838010
Does the KN-522 data change your decision about chemo regimen?
In the absence of side effects, would you be inclined to continue beyond 10 years as chemoprevention? Would you factor an intermediate/high oncotype R...
Would you treat this differently than someone who only presents with axillary nodal disease?
How would you manage symptoms? How would you adjust the adjuvant regimen (dose reduce, omit paclitaxel etc)? What strategies would you consider for pr...
This is a patient with a 1.8cm node negative HER2 positive tumor that is grade 3, high Ki67, and ER positive.
Data presented at the 2017 SABCS (abstract GS1-01) of the EBCTCG meta-analysis stating a benefit of dose-dense chemotherapy applies to ER positive and...
Germline genetic testing negative
Are there clinical scenarios in which 5 years of tamoxifen alone remains sufficient?
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Would you offer AI + OFS or tamoxifen to a woman with a grade 3 T2N0 tumor and OncoType of 15?
Additionally, would the finding of any mutations, such as ESR1, change your recommendation?
Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...
History of Multiple Myeloma with renal failure currently on velcade.
For example, is this still your approach in women with small tumors or node negative disease?
Example: Low grade mucinous tumor post bilateral mastectomy
2D Echo - Normal Ejection Fraction
Would you offer adjuvant chemotherapy to a post-menopausal woman with a BRCA2 mutation and a T2N0 ER positive breast cancer with an oncotype of 12?
It is included in favorable histologies on NCCN, but no mention of how to treat based off HER2 status.
Patient only had upfront surgery.
She had disease progression on palbociclib and letrozole. She also has a PIK3CA mutation however did not tolerate alpelisib due to Grade 3 hyperglycem...
How would you specifically treat a grade 1, but HER2 positive lobular?
Patient has grade 3, pT3N0 disease and is s/p lumpectomy.
PDL1 status pending; BRCA wild type
Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...
Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?
Does the results of the tnAcity trial influence your decision in choosing a 1st line option?
Status post nasolacrimal stent with improvement. Would you re-challenge or permanently discontinue docetaxel?
More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?
How would you figure out how to treat someone with a prior localized HR+,HER2- breast cancer treated with adjuvant AC-T (5years ago) and a recent ipsi...
Would you consider an aggressive approach with RT and/or surgery to the bone lesion and treat the primary as locally advanced breast cancer?
Do you use anti-hormonal therapy for these patients?
Role of neoadjuvant TC vs. anthracycline based regimen?
How would you approach a post-menopausal woman who now wishes to start adjuvant endocrine therapy more than 3 years since surgery?
Would you prefer first-line AI/CDK 4/6 inhibitor, or first-line AI followed by 2nd-line fulvestrant/CDK 4/6 inhibitor (either abemaciclib, once availa...
If finished adjuvantly, what would you do -- continue TC or change chemotherapy?
If yes, would you still recommend dual HER2 directed therapy?
After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...
Rationale for adjuvant therapy was high Oncotype score.
Given that DBA is associated with increased incidence of MDS, AML and other solid tumors, would this modify your treatment recommendations?
For early stage disease in a single breast, would you consider neoadjuvant chemotherapy or upfront surgical staging followed by adjuvant therapy? What...
RP node with treatment related changes and surgical specimen from TAH/BSO no other foci of malignancy found.
Do you tailor treatment to a goal response? Do you refer to data illustrating improved prognosis if the patient develops a CR or PR?
Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...
Could carboplatin be considered here? Or any evidence for a PARP inhibitor?
Liquid biopsy also showed AR amplification.
If so, after how many cycles of chemotherapy would you switch?
PIK3CA and ESR1 mutations on NGS without other targets and who has progressed on CDK 4/6 & AI and several single agent chemotherapies. Aside...
Does hormone receptor status impact your decision?
What would you use either in adjuvant setting or in metastatic setting?
Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.
I have seen some advocate for this in the community, although a Cochrane metanalysis did not find an advantage to giving the taxane earlier.
In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...
Would you forego anthracycline?
Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...
The ABC trials (Blum, JCO, 2017) used six cycles of TC. Is it because of the superiority seen with TC x four cycles versus standard AC x four cycles (...
Often patients are referred to medical oncology for adjuvant therapy for early stage breast cancer after BCS and just before starting radiation.
Do you see a role for adjuvant radiation therapy?
These patients were excluded from the SOLAR-1 trial.
Tumor measured 3 mm.
She developed biopsy proven skin nodules while on paclitaxel. PDL-1 positive and BRCA negative. Would you consider atezolizumab with a different agent...
She is otherwise asymptomatic and no LFT abnormalities. Would you switch to chemotherapy or offer different endocrine therapy?
Patient has hot flashes.
Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...
Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?
If so, would you treat as node + BC with anthracycline and taxane regimen or non-anthracycline regimen (i.e docetaxel and cyc...
She developed isolated paraspinal recurrence that is not amenable for local therapies including RT.
Patient defers chemotherapy. She is currently on anastrozole/Herceptin and perjeta with a response but it is suboptimal. I would like to add a CDK 4/6...
The patient received THP and now is on maintenance HP when she developed CNS disease.
She had a ipsilateral chest wall recurrence after mastectomy ~5 wks after surgery that was known TNBC. Residual disease remained in known breast and a...
Initially stage 1 disease with high risk Mammaprint recurrence risk completed adjuvant chemo 15 months ago.
Data was presented at ASCO in 2017 that abemaciclib has brain activity in HR positive breast cancer.
She had not received any systemic therapy previously.
Most guidelines recommended adjuvant chemotherapy if tumor size was >3cm at the time of TAILOR Rx and patients with tumors >5cm were not include...
greatest measuring 1.0cm.
Or would you proceed with standard-of-care adjuvant approach for high risk patients?
The use of neoadjuvant CDK 4/6 inhibitors is not standard of care, but there are clinical trials looking at this question and patients who are chemoth...
AI+ CK4/6 inhibitor? Fulvestrant + CK4/6 inhibitor? AI + fulvestrant? AI + fulvestrant + CK4/6 inhibitor?
I.e. according to Mammaprint test?
Would it make a difference in terms of OS if the patient received AC?
Would you proceed with modified radical mastectomy followed by systemic therapy, or would you consider neoadjuvant therapy? Would biomarker status mat...
Does the presence of N1 disease push you towards offering chemotherapy or would you continue endocrine therapy based on the PR?
In addition to gabapentin and Lyrica, what else can you do for chemotherapy induced neuropathy?
Favored approach: AC-T +\- carboplatin, +\- gCSF
The patient has been off her AI for two years.
She has hepatorenal failure due to metastatic disease.
Have you used anti-androgen therapy? Do you enroll patients on a trial or treat off label?
No viable cell was present.
What factors influence your decision?
Which patients should receive TDM-1, Trastuzumab+Pertuzumab or Trastuzumab alone?
In obese patients, would it make sense to switch from a GnRH agonist to an antagonist based on the data from the recent JCO study of dagrelix vs. trip...
NCCN recommendations seem to mention these patients as not candidates for preoperative systemic therapy if the invasive carcinoma extension cannot be ...
Patient did not receive neoadjuvant therapy.
What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...
Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab
Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?
Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...
If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?
The ABC trials show a DFS advantage of anthracycline-based regimens. Would age alone procure you from using it in a patient?
Any factors that would impact this decision (how far along adjuvant trastuzumab, disease characteristics, etc)?
This patient is a young lady with stage IV ER/PR positive, Her2 negative with oligometastatic breast cancer undergoing a planned bilateral oophe...
The CALOR trial included patients that could receive HER2-targeted therapy.
Only a small subset (22-24%) of patients in Katherine trial received a non-anthracycline containing regimen.
Can repeating Oncotype on a locoregional recurrence show a change in the biologic behavior of the cancer over time and guide treatment decisions?
The recurrence was 2 years after treatment with ddAC + T. If you elect for systemic therapy after local therapy, what chemotherapy would you use...
The patient completed AC-T three years prior.
Would you consider neo-adjuvant chemotherapy or treat with endocrine therapy?
One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone. How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...
What patient and disease factors may influence your decision?
Do your recommendations differ if patients are pre or postmenopausal given the data?
For instance, in stage III, would you use chemotherapy in neoadjuvant or adjuvant setting? What regimen would you use?
For example, in a patient > 70 years old?
Have the results from IMpassion130 changed the standard of care?
She otherwise does not have any BRCA mutations nor any underlying cardiac disease.
And how long? According to the ABCSG-16 Trial there was no difference in extending AI beyond 2 years after an initial 5 years.
Will you incorporate the results from KATHERINE into clinical practice now?
The CREATE-X trial did not include HER-2 positive patients but the ER-negative population benefited from capecitabine. Would you consider capecitabine...
Hormonal therapy would not be tamoxifen.
Does the answer vary based on whether it is neo/adjuvant or metastatic setting?
How applicable is the SOFT/TEXT data in this setting ?
Analyses have showed questionable benefit with chemotherapy
One example is the original breast cancer ER high 90%, PR mod to high 40%, Her2 negative. A liver metastasis diagnosed 2 years later showed ER l...
What are your thoughts with the new KEYNOTE-522 regimen? Would you just use carbo/paclitaxel/pembro part of the regimen or give as much doxorubicin as...
OS benefit was limited to patients with endocrine sensitivity, defined as either a documented clinical benefit (CR, PR, or SD for ≥24 weeks) f...
What is the ideal timing for monitoring and what laboratory tests should be used?
Initial pathology additionally yields low Ki-67 and is HER2 negative.
Does an age over 70 years, size, histology and hormone receptor status affect this decision?
The patient is relatively asymptomatic.
The patient only had disease involving the right breast and axillary, cervical, and supraclavicular lymph nodes. She had complete response to with ddA...
Essentially, is there any role for "COMET trial" type therapy for a low risk elderly patient?
Is TC or CMF adequate or is only ddAC -> T recommended?
(HER2/CEP17 ratio <2.0, copy number >4.0 and <6.0 signals/cell)
There is a gray area in clinical decision making where the practice seems to be different for borderline size tumors such as a 7 mm T1b lesion with no...
If yes, what dosage and do you use it continuously or intermittently? Regarding provera, many patients with ER/PR (+) breast cancer worry about taking...
Do you test for pregnancy prior to each cycle?
Not to decrease recurrence risk, but for chemoprevention of new ER-positive DCIS or invasive disease based on the Gail Model. If so, is there data to ...
How does the timing of recurrence play into your decision?
The patient is a pre-menopausal woman with low-grade, stage I IDC who initially could only tolerate 10 mg of tamoxifen for her first year of trea...
Young woman with Her2 positive disease involving her right breast, regional lymph nodes, and liver had a CR on PET after therapy with THP and now plan...
The NEJM 2015 paper by Tolaney et al only included 1.5% of patients with micrometastases.
If a patient has ER/PR+ and Her2 positive disease in the primary tumor while axillary lymph node core biopsy is ER/PR+ Her-2 negative, do you man...
If so, what is the ideal imaging?
Pt is healthy and tolerating Tamoxifen well.
In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...
Can these patients be re-challenged with Herceptin?
When would you sequence radiation?
Specifically, this patient had a new left lacrimal gland metastatic lesion that developed four years from her initial diagnosis and is currently under...
Would you do this for ER+ patients?
According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
What factors if any would influence your decision and what would your approach be?
Would you give neoadjuvant chemotherapy in a patient with T1 N1 M0 ER/HER-2 positive cancer if they are candidates for upfront lumpectomy?
If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?
Is there any evidence to use trastuzumab and pertuzumab without doxorubicin?
High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.
Many times we encounter patients who do not have a tissue sample readily available or in whom obtaining such a sample would be hard. On a more molecul...
The PERSEPHONE trial to be presented at ASCO suggests 6 months of Herceptin is non-inferior to 12 months in early Her2 postive disease.
If so, how frequently?
First episode was 10 years ago and patient did not receive XRT. Would you give XRT now?
What is the optimal regimen for a pre-menopausal female with progression of ER+,PR+ and Her2 neu negative breast cancer while on tamoxifen for six mon...
Do you consider it only in lymph-node negative or up to three lymph nodes?
The patient initially had a great response to THP for four months, but now with quite a bit of lung, pleural, and nodal involvement.
Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?
Intramammary lymph node involvement has been shown to have a poorer prognosis (Hogan, Surg Onc, 2010). Would Oncotype be useful in these patients...
Would you consider capecitabine in addition to paclitaxel?
Is there any data to support this?
No prior chemotherapy.
Knowing that the analysis now is more detailed than it was 10 years ago.
What about non-Ashkenazi Jewish breast cancer patients with suspic...
While we await the results of TailorX, what has been the experience in your practice? If the decision for adjuvant chemotherapy is made, do you f...
Do ER/PR and HER2 markers have any role?
Would you use oncotype to guide your decision?
Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
Originally received anthracycline and taxane based regimen.
Would you use carbo/paclitaxel or capecitabine or a different approach?
Is there any data on safety of radiaiton with pertuzumab?
Is there a difference among all the commercial genetic testing labs? Is there anything beyond CLIA- and CAP-certification that we should look for...
After mastectomy for the locally recurrent disease, would you consider "pseudo-adjuvant" chemotherapy for local recurrence per the CALOR trial? If so,...
Can you apply the ACOSOG Z0011 study to women who have HER2 positive disease?
Recent NEJM study showed an increased breast cancer relative risk in longer durations of hormonal contraceptive use that could last up to 5 years. Pre...
An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...
Pt has progressed on AI and Faslodex. Goal is radiation to axilla as a palliative intent and Capecitabine to control systemic disease.
Are you using post-neoadjuvant Xeloda based on preliminary data from the CREATE-X trial? Does BRCA mutation influence your decision?
If so, when? Are there certain ERBB2 mutations that would predict response to trastuzumab and/or neratinib?
Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.
Would you consider using CKD inhibitors upfront in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Hercepti...
Does resection have an impact on survival?
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
Using an AI if a woman is taking an estrogen supplement seems counterproductive.
Assuming the patient was initially treated with surgical resection and adjuvant chemotherapy followed by radiation and appropriate endocrine therapy.
What do you do with low grade (grade 1/3) tumors? In other words, does high grade pathology over rules?
In light of two phase III randomized trials showing duloxetine (S1202) and acupuncture (S1200) both improve AIMSS, which would you try first? Wou...
Would the exact Oncotype score guide your decision (ie closer 25-30 v. >30-35)? NCCN recommends Oncotype only for tumor size < 5mm but this case...
Do you send Oncotype in patients with ER/PR+ breast cancer and micrometastasis in one sentinel node?
If Oncotype is high risk, what regimen of adjuvant chemotherapy would you recommend?
Would you use a regimen with lower incidence of neurotoxicity such as CMF or a taxane-based regimen with a low threshold to dose-reduce?
Would you consider using ckd inhibitors in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Herceptin? NCCN ...
How do you approach treating ER/PR positive/HER-2 positive metastatic breast cancer? Do you combine hormonal therapy / chemotherapy and HER-2 directed...
We often treat elderly women with lumpectomy and adjuvant hormonal therapy without radiation. I am concerned about how to proceed after the 5 year poi...
Many women are distressed when asked to discontinue hormone replacement therapy or use intravaginal estrogen suppositories.
Some patients request chemotherapy scheduling adjustments to avoid feeling ill on major holidays. Delaying chemotherapy by a few days isn't of particu...
Example case: Patient given neoadjuvant docetaxel + cyclophophamide achieves a partial response after 3 cycles of Taxotere + cyclophosphamide but is u...
Are results of BCIRG-006 trial applicable for patients with triple positive breast cancer or only for those with HER2+?
How often will you monitor it? In the setting that patient is morbidly obese, does your strategy change?
Tamoxifen prophylaxis is FDA-approved, but would you extrapolate from adjuvant/metatastic data for hormone receptor positive breast cancer in post-men...
In the absence of data demonstrating a clinical benefit for one strategy versus the other, what do you do in practice?
Being that there is limited data on CNS penetration with either regimen, what would you prefer in a patient who already received whole brain RT?
The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.
If so, what regimen?
Do you have a cutoff in terms of tumor size, number of LN, Oncotype score, etc that makes you choose lower vs higher intensity chemo?
There is limited data that suggests steroidal AI exemestane could be of some benefit after nonsteroidal AI failure (Lonning PE et al. J Clin Oncol 200...
For example, would you order a PET/CT to evaluate for lymphatic or distant metastatic disease?
Does your institution do this routinely?
I.e. either for treatment of high-risk disease or intolerance/contraindication to tamoxifen. Will you continue it for the full 5 year course?
Do you prefer doing this through a "neoadjuvant" approach vs. post-operatively?
CALOR trial
How does the modest results of the APHINITY trial impact your practice?
In a patient with isolated leptomeningeal disease (no systemic disease), would you still recommend systemic therapy?
Assume good compliance with oral therapy, equivalent access to either agent, no contraindictions to either therapy, and absence of any visceral crisis...
Do you reserve this approach for only women with triple negative breast cancer or all-comers?
Given the poorer prognosis of these patients, do you approach their treatment any differently than a unilateral cancer?
Is this in addition to or mutually exclusive from oncotype/mammaprint?
Patient has hormone-refracatory disease, had high visceral burden (pulmonary mets, bone, lymph). Progressed on taxane, xeloda, gemcitabine. Now ...
What would you choose if there is no response to neoadjuvant AC-T? Taxol, THP, TCHP?
Do you prefer neoadjuvant chemotherapy or proceeding directly to surgery, followed by adjuvant therapy?
Assuming cytotoxic chemotherapy is given, would you still then proceed with adjuvant endocrine therapy? Would you switch agents or classes of en...
(For instance, TCx4 instead of ddAC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemother...
Do you prefer this approach based on the FALCON trial showing improved PFS with frontline fulvestrant?
Do you extrapolate the results of OPTIMIZE-2 and CALGB 70604 showing that an every 12 week dosing of zolendronic acid is noninferior to ever...
Is there a select patient population that you use it for? Is it also being used in cancers other than breast cancer?
There are many options to choose from, including large gene panels with up to 80 genes at the same cost as BRCA 1/2 testing, while others offer j...
Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...
Are there differences between palbociclib and ribociclib? What would make you choose one over the other?
Example patient: 50 year old pre-menopausal woman with a familiy history of pre-menopausal BRCA1 and BRCA2 wild-type breast cancers in sister and...
For example, if a post-menopausal patient is treated in the first line setting with docetaxel, herceptin, and perjeta, would you add an aromatase...
At what point do you send these test, and in what instances do the results influence your treatment recommendations?
If so, how do you counsel patients who are node positive with low or intermediate risk scores? How do you interpret the existing data? NCCN and ASCO g...
In a patient who underwent lumpectomy for presumed DCIS and was found to have a focus of invasive triple negative disease, would you offer chemotherap...
Is a monthly schedule x 1 year, followed by q3 months, now the the standard of care, as per the recently published OPTIMIZE-2 trial?
Is it more/less helpful if CA 15-3 is negative?
This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?
Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...
The CALOR study showed a benefit of adjuvant chemotherapy for local recurrence but the regimens given were "physicians choice".
How do you counsel them on risk in the curative setting? Do you approach treatment in the metastatic setting any different than patients with &g...
Does switching AIs help? If so, is there a role for switching from a steroidal AI to a non-steroidal AI or vice versa? Are there other adj...
Based on results from PALOMA1 and recently reported MONALEESA2, do you use a CDK4/6 inhibitor as initial therapy? In what circumstances would yo...
Does your recommendation change depending on the agents they received?
The results of the 70 gene panel Mammaprint in combination with Adjuvant! Online were published in NEJM recently. How will you incorporate this data i...
Do you ever consider de-escalating or stopping therapy in this situation? What is your approach to this conversation?
The MA17R trial only included "postmenopausal women" so how do you make a decision for men and pre-menopausal women.
What if the patient has a BRCA1/2 mutation?
The patient has refused termination of pregnancy.
What about patients with bone-only metastases?
Do you use cytotoxic chemotherapy as first line or hormonally-targeted therapy such as letrozole + palbociclib?
Based on the CALOR trial (http://www.ncbi.nlm.nih.gov/pubmed/24439313), adjuvant chemotherapy should be considered, but what regimen is preferred?&nbs...
In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...
The recently published MA.17R trial showed a DFS benefit for extending AI therapy to 10 years in post-menopausal women.
Assuming the patient is a candidate for either of these treatments?
A recent publication of the TEXT and SOFT trials http://www.ncbi.nlm.nih.gov/pubmed/27044936 showed an improvement in breast cancer-fre...
Do you routinely do Oncotype DX testing in these patients?
Are there any clinical or pathologic factors that lean you towards or away from giving trastuzumab?
Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.
Are all bisphosphonates equal in its efficacy? What dose?
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