Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a postmenopausal female with localized ER+ breast cancer on adjuvant anastrozole with a rising estradiol level?
First, I do not usually check estradiol levels in my patients on an aromatase inhibitor, in part because many of the available estradiol assays are not very accurate, and because the AIs are so effective at blocking estrogen production. However, now that you have this value, the first thing I would ...
How do you approach a pre-menopausal female with HR+ breast cancer with discordant IHC and OncotypeDx ER expression?
There are multiple reasons this can happen. The RNA and protein for ER have different stability in FFPE, heterogeneity between the biopsy sample used for IHC vs the surgically resected tumor used for Oncotype, or a failure to properly amplify the transcript from the sample provided are some causes. ...
For a post-menopausal patient with a pT2N0 HR+/HER2- breast cancer at surgery after 4 months of neoadjuvant anastrozole with minimal clinical or pathologic response, would you utilize genomic testing to guide decision about adjuvant chemotherapy?
This is a very relevant question as we are treating more patients with neoadjuvant endocrine therapy in the COVID-19 era. Ki67 and other markers can respond promptly after neoadjuvant hormonal therapy, it may take longer than 4 months to judge the clinical and histological response. If this is a pat...
Would you offer adjuvant chemotherapy for 1-3 node positive HR+, HER2 negative breast cancer with Mammaprint low risk to a young, pre-menopausal patient?
Until we have the results from the RxPONDER trial (which used Oncotype, not Mammaprint, but addresses this question more directly than MINDACT), we cannot rule out a potential benefit from adjuvant chemotherapy in node-positive patients like these, and thus, I would offer it while saying that the be...
When would you offer ovarian suppression in addition to endocrine therapy for premenopausal women who omit adjuvant chemotherapy?
If a premenopausal woman has a hormone receptor positive breast cancer for which chemotherapy is recommended, but chooses to omit the chemotherapy, I would recommend ovarian suppression or oophorectomy in addition to endocrine therapy. I also typically describe the added benefits of ovarian suppress...
Will you use ovarian function suppression in lieu of chemotherapy in premenopausal patients with pN1 ER+ HER2- breast CA with OncoType RS <25?
Most certainly. The difference between chemotherapy effect in postmenopausal vs. premenopausal women with ER+ breast cancer is not primarily due to a difference in disease biology. It is due to the endocrine effect of chemotherapy in premenopausal women and the lack of that effect in postmenopausal ...
Are you more inclined to offer adjuvant chemotherapy for a post-menopausal woman after lumpectomy for a small TNBC who has a concurrent metastatic ER+ breast CA?
This is an unusual situation. I would not give adjuvant chemotherapy to this patient who already has metastatic disease, even indolent metastatic disease. First, the chance of developing metastatic disease from the triple-negative breast cancer is not 100%, it's more like 20-40% depending on how sma...
What are your recommendations for post-menopausal patients who would fit into RxPonder trial criteria (HR+/HER2- breast cancer, 1-3 positive LNs) and have already started on adjuvant chemotherapy?
It would depend on where the patient is in the journey. If she is having problems with the chemotherapy, it might be beneficial to send in order to feel better if you are thinking of stopping chemo early anyway.
What is your neoadjuvant chemotherapy of choice in patients with ER+ breast CA who are receiving neoadjuvant therapy with goal to convert to BCS from mastectomy?
I have tried to use Dose dense doxorubicin and cyclophosphamide followed by dose dense paclitaxel (AC-T) in most situations in the neoadjuvant setting since lymph node status is not known definitively prior to surgery. There is adjuvant data from the ABC trial for non inferiority of docetaxel and cy...
What adjuvant treatment (if any) would you recommend for a post-menopausal patient with a borderline T1b (0.5 cm) grade 2 ER+/PR+/HER2 negative invasive lobular breast CA after bilateral mastectomies?
My evaluation and plan for any patient with breast cancer seen in the Stage 0-3 setting tends to follow a similar pattern. The risks include: Distant recurrence Local recurrence New breast primaries Side effects of therapy The systemic therapy options for lowering these 3 categories of risk in this ...