Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Should we start performing universal germline mutation testing for all newly diagnosed breast cancer?
The OlympiA study resulted in a statistically significant iDFS and DDFS benefit with adjuvant olaparib vs placebo in high-risk, HER2-negative patients with gBRCA mutation. Given the notable improvement in outcomes, it is imperative that every potentially eligible patient be considered for adjuvant o...
In a patient with HR+ breast cancer who is not able to tolerate adjuvant AI or standard dose tamoxifen due to side effects, would you consider a lower dose of tamoxifen?
Since we don't have data on the efficacy of low dose tamoxifen for treatment of invasive cancer, this would be a last resort. The TAM01 trial showed 5mg of tamoxifen was better than placebo for preventing recurrence in women with intraepithelial lesions. Anecdotally, I have had an occasional early s...
Would you modify the dose of aromatase inhibitors or selective estrogen receptor modulators in patients who have a history of gastric bypass or other malabsorptive conditions/surgeries?
This is an interesting question as we are certainly seeing more patients having weight loss surgeries. There is really limited data on the absorption of aromatase inhibitors (AIs) or selective estrogen receptor modulators (SERMs) after gastric bypass or other GI surgery. In general, drugs that are f...
Would you offer endocrine therapy to a patient who developed a new contralateral pT1b pN0 ER/PR+ HER2- breast IDC 1 year after coming off 10 years of anastrozole for prior invasive breast cancer?
I would offer the patient endocrine therapy but would use a different endocrine agent than one the patient had been on for the previously diagnosed contralateral breast cancer. Since this patient was on anastrozole for 10 years (a non-steroidal aromatase inhibitor), I would probably choose a steroid...
What is your treatment approach in a patient with cT2 ER+HER2+ breast cancer who refuses neoadjuvant chemotherapy?
Standard neo-adjuvant chemotherapy that contains trastuzumab, pertuzumab carboplatin, and docetaxel is recommended for most cases of HER2+ breast cancer (although other, anthracycline-containing regimens also exist but are used increasingly less commonly). If this patient refuses neo-adjuvant chemot...
Do you discontinue anti-hormonal therapy if a high-risk ER+ HER2- localized breast cancer patient develops blood clots on anti-hormonal therapy?
Tamoxifen has been associated with an increased risk for venous thromboembolic events, but there does not appear to be any increased risk with the aromatase inhibitors in the placebo controlled studies. These include MA.17, MA.17R in the extended endocrine therapy setting and MAP.3 and IBISII in the...
Do you give chemotherapy to women with clinical features of high risk ER+ breast cancer, but a low Oncotype DX score?
I wouldn't consider chemotherapy in this patient but some would. I will try to briefly summarize the arguments on both sides. - Prior to oncotype, we made the decision about chemo based on anatomic risk alone. If the risk of recurrence was predicted to be 10% or greater, guidelines suggested chemoth...
Do you discontinue anti-hormonal therapy if a high-risk ER+ HER2- localized breast cancer patient develops blood clots on anti-hormonal therapy?
Tamoxifen has been associated with an increased risk for venous thromboembolic events, but there does not appear to be any increased risk with the aromatase inhibitors in the placebo controlled studies. These include MA.17, MA.17R in the extended endocrine therapy setting and MAP.3 and IBISII in the...
What other chemotherapy would you consider in a patient with high-risk node positive ER+, HER2- disease that developed pulmonary toxicity to paclitaxel and refuses any more taxanes?
This is certainly a tough situation, but one that comes up when we cannot complete what we think is sufficient adjuvant therapy with the taxane portion of the adjuvant chemotherapy regimen, AC-weekly Taxol. In most cases, we would consider an alternate taxane, but not in this case because the patien...
Is there a role for the neoadjuvant use of CDK 4/6 inhibitors with endocrine therapy in patients with well differentiated and/or invasive lobular histology who desire breast conservation?
The role of neoadjuvant CDK4/6 inhibitors has been explored in multiple phase 2 trials including the neoMONARCH and PALLET trials. The data from these studies suggest that abemaciclib and palbociclib are active in ER+ early stage breast cancers by causing a more complete arrest of tumor cell prolife...