Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What endocrine therapy would you recommend for a perimenopausal female with a low risk Oncotype, HR+, HER2-negative, SLNB negative breast cancer who is clinically postmenopausal but with FSH, LH and estradiol that are not in the postmenopausal range?
In this situation, with a low risk, node-negative disease with ambivalent menopausal status, Tamoxifen, unless contraindicated, would be my choice. A SERM is equally effective for premenopausal and postmenopausal women. In the course of adjuvant endocrine therapy, changing to an aromatase inhibitor ...
How do you approach treatment in premenopausal patients who develop a contralateral HR+ breast cancer while already on tamoxifen and ovarian function suppression?
Several pieces of information are lacking in this clinical case to make a solid treatment recommendation: what is the current age of the patient? What is her menopausal status? Is the new contralateral breast cancer clinically node negative? Since this new second primary contralateral breast cancer ...
What adjuvant therapy would you offer an elderly but healthy patient with T2N1 HR+ HER2+ breast cancer who is not willing to receive cytotoxic chemotherapy?
The Japanese RESPECT trial (Sawaki et al., PMID 32936713) compared trastuzumab alone (T) vs chemo+trastuzumab (Ch+T) in patients >=70 and demonstrated a 3 year DFS of 89.5% (T) vs 93.8% (Ch+T) HR 1.31 p=.51. Based on this data, you could discuss adjuvant AI+trastuzumab for 1 year.
Does the magnitude of OncoType recurrence score above 26 inform decision between TC and AC/T in ER+ HER2- 1-3 node positive, postmenopausal patients with breast cancer?
We don't have any evidence for correlating recurrence score with choice of chemotherapy. Based on RxPONDER, we know that patients with 1-3 positive lymph nodes and scores less than 25, do not benefit from chemotherapy. Based on retrospective data, we have enough evidence that scores more than 30 wou...
Would you offer adjuvant abemaciclib to young, premenopausal women desiring more children who meet criteria for the same based on monarchE trial?
Based on the package insert for abemaciclib, there is no reported risk of early menopause or amenorrhea. CDK4/6 inhibitors are cytostatic (by blocking the transition from G1 to S phase) and not cytotoxic, unlike alkylating chemotherapy. So, I would feel comfortable offering abemaciclib and subsequen...
Would you consider adding neoadjuvant endocrine therapy in a patient with HR+, HER2- breast cancer who has not clinically responded to neoadjuvant chemotherapy?
Generally no, unless conversion to lumpectomy is a goal. If the patient is not a lumpectomy candidate, then I would move on with surgery. Pathological complete responses are low (10%) in ER+ive cancers, thus it is not unusual to see a modest clinical response with chemotherapy.
How do you approach discussion of adjuvant chemotherapy for a T1b (0.5 cm) hormone positive breast cancer with high risk features and an Oncotype Score of 31?
The best available data suggests that the relative benefit of chemotherapy predicted by gene profiling scores is seen across anatomic stages, but the absolute differences in smaller size node negative tumors will of course be smaller, even with a higher Oncotype Dx score. While precise estimates are...
How would you approach a post-menopausal women with recurrent ER/PR+, HER2- breast cancer only in the axillary lymph nodes?
This sounds so characteristic of a low-grade ER+ tumor in an elderly lady. I would only resect and confirm at resection the above-suspected pathology. Clearly given her age indolent behavior, local recurrence and low volume I would not torture this elderly lady with nothing more than an AI. The prob...
How would you approach a postmenopausal woman with Stage I HR+,HER2- breast cancer who had a CVA while on tamoxifen?
A major co-morbidity such as a stroke should prompt a re evaluation of the benefit risk ratio and overall value of adjuvant endocrine therapy, especially for low risk disease. It would be helpful to unpack this situation a little more. How bad is the stroke and how much loss of mobility and performa...
Do you approach the treatment of post-lumpectomy DCIS which is only present within an intraductal papilloma differently, if it does not involve adjacent breast tissue?
From the medical oncology perspective, I would consider chemoprevention with endocrine therapy for this patient. Prior series have shown elevated relative risk in patients with papillomas with atypical cells (although not as high as DCIS itself). I am not sure about the size of the DCIS within the p...