HR+   

Patient has progressed through prior lines of endocrine therapy. 

Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?

 Would you consider gene profiling to determine need for chemotherapy?

ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.

Knowing the differential effect seen with menopausal status in RxPONDER, would you avoid chemotherapy or still offer chemotherapy, given that only 15....

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.

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?

2 populations of cells with 95% negative by FISH (ratio 1.07) and 5% positive by FISH (ratio 10)

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?

Would you consider ALND and /or XRT to axilla?

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. 

She had already completed ddAC and two cycles of paclitaxel before the reaction.

For example, if a post-menopausal elderly woman has a small focus of node positive disease, would once consider adjuvant abemacicliib + endocrine ther...

Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?

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 ...

Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?

Interest in approach for elderly population especially 

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?

Do you give first line CDK 4/6 inhibitors with Tamoxifen or Aromatase Inhibitor (+/- GnRH analogue)?

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)

With the recent announcement that the phase 3 MonarchE trial met its primary endpoint. 

She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?

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. ...

N1mic - few isolated malignant cells in 1 axillary lymph node

Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.

< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.

Masuda et al., NEJM 2017

If so, please describe your experience and dosing.

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...

Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...

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 your choice vary based on the patient's gender?

Would you consider delaying chemotherapy and proceeding only with endocrine for now?

Initially treated with anastrozole, current treatment is with fulvestrant.  

No primary identified in the contralateral breast. No distant metastasis identified.

IHC: ER 70%; PR 70% OncotypeDx: ER - Negative; PR - Positive

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)...

Stage T1bN1mic

Pre-treatment estradiol: <5 Estradiol after 1 yr: 35

https://www.ncbi.nlm.nih.gov/pubmed/31838010

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...

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...

Are there clinical scenarios in which 5 years of tamoxifen alone remains sufficient?

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? 

Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...

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.

She had disease progression on palbociclib and letrozole. She also has a PIK3CA mutation however did not tolerate alpelisib due to Grade 3 hyperglycem...

Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?    ...

More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?

Prior localized HR+,HER2- breast cancer treated with adjuvant AC-T (5years ago) Recent ipsilateral axillary recurrence (HR-,HER2+) s/p neoadjuvant TC...

Would you consider an aggressive approach with RT and/or surgery to the bone lesion and treat the primary as locally advanced breast cancer?

Role of neoadjuvant TC vs. anthracycline based regimen?

Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...

The patient received THP and now is on maintenance HP when she developed CNS disease.

Initially stage 1 disease with high risk Mammaprint recurrence risk completed adjuvant chemo 15 months ago. 

Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab

One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone.  How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...

For example first-line ribociclib/letrozole, and second-line palbociclib/fulvestrant?  Without data, would there be any expected benefit?

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 lesion with no oth...

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?

Assume good compliance with oral therapy, equivalent access to either agent, no contraindictions to either therapy, and absence of any visceral crisis...