Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a postmenopausal woman with recurrent, localized ER+,HER2- breast cancer to the contralateral breast while on AI?
Assuming this a new primary, you would treat it like another primary breast cancer with breast surgery +/- radiation. If clinically appropriate you would send genomic testing (i.e., Oncotype or Mammoprint) to make decisions about adjuvant chemotherapy. The contralateral breast cancer (CBC) recurrenc...
What factors influence whether you order OncotypeDx in HR+ node negative ILC?
If there is differential ER/PR expression or other high risk features such as pleomorphic features or high grade.
Would you use neoadjuvant CDK4/6 inhibitor and AI in HR+ breast cancer based upon the randomized phase II CORALLEEN trial?
I would not use CDK inhibitors in the neoadjuvant setting.
How does age factor into your planning whether to give a high risk pre-menopausal patient with breast cancer ovarian function suppression?
Generally, my age cutoff is 50, but it depends on the patient’s documented menopausal status prior to chemotherapy. If the patient is perimenopausal, then I initiate ovarian suppression plus aromatase inhibitor and check estradiol and FSH every 12 months. When she is clearly post-menopausal, then I ...
Would you consider adjuvant capecitabine in a premenopausal patient with HR-positive inflammatory breast cancer who had residual disease after neoadjuvant chemotherapy?
Yes, I would consider adjuvant capecitabine for a patient with residual invasive disease after standard neoadjuvant chemotherapy (NAC) for HR+ inflammatory breast cancer. Given the uncertainties about the absolute benefit in recurrence and mortality in this specific situation, I would discuss this w...
How would you approach adjuvant therapy for a young post-menopausal woman with a grade 3 pT1a (5mm) node negative ER+/HER2- invasive ductal carcinoma?
There is no data from the prospective trials to support genomic testing in T1a tumors. TAILORx did not enroll T1a tumors. A G3 tumor under 1cm is clinically low risk so Mammaprint would not have clinical utility either. Since NCCN doesn't recommend chemotherapy in this scenario, I would not test.
How would you council a woman in her 50s with Stage I HR+/HER2- breast cancer with a high risk Mammaprint but intermediate OncotypeDx regarding adjuvant chemotherapy?
This is a challenging question to address without more details. The first question is why were two different assays run on the tumor? Also, in the context of the TAILORx data which demonstrated a lack of benefit from chemotherapy for postmenopausal women with Oncotype DX recurrence scores 25 or less...
In cases in which Oncotype DX test is not available, how do you decide which patients with HR+ and Her2- breast cancer are candidates for adjuvant chemotherapy?
If OncotypeDx is not available for an ER+ Her2- primary breast cancer: In general, there are two main components to the 21 gene assay: proliferative thrust and estrogenic signaling. Thus tumors that have strong staining for ER tend to be driven by estrogenic signaling. This is especially true if th...
Would you consider using OncoType Dx testing in a patient with breast cancer if nodal evaluation is not performed?
In women who are 65 and older who have clinically negative axilla, there are less node assessments done with BCS, given data showing they do not add very much. If the patient is otherwise a candidate for adjuvant chemotherapy, I do check a genomic expression profile, either OncotypeDX or MammaPrint....
Would you still obtain Ki-67 prior to use of adjuvant abemaciclib in a patient who has otherwise met MonarchE treatment criteria, such as 1-3 positive LNs, grade 3 and/or tumor >5 cm?
In the setting of a patient with residual disease after NAT with an initial grade 3 stage IIIA ER positive breast cancer, I would treat with adjuvant abemaciclib regardless of Ki67 status if the absolute risk of recurrence was high enough. pCR rates after NAT for ER positive breast cancer are low, a...