Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you counsel a patient with HR+, HER2- breast cancer with an OncotypeDx ROR score of 0 who is refusing endocrine therapy?
This is often a challenging case to discuss with patients. Although we know that this patient's likelihood of distant recurrence is very low if she takes 5 years of adjuvant endocrine therapy, we don't actually know what her risk of recurrence is with no systemic therapy. Presumably, those with very...
Would you treat a postmenopausal women with high grade T2N0 ER-, PR+, HER2- invasive ductal carcinoma with upfront surgery or neoadjuvant chemotherapy?
I'd conduct a conversation about NAC, but it isn't clear to me that NAC would change anything for this patient. PR 45% does not qualify as "functionally triple negative" in my book, so I'd consider this still HR+. I would not offer more than AC-T whether NAC or adjuvant. Additionally, I wouldn't off...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
Would you use OncoType in a postmenopausal female with HR+/HER2- with LN involvement who clinically meets RxPONDER criteria of 1-3 LN to guide the use of neoadjuvant chemotherapy?
Yes. If I am asked to consider neoadjuvant therapy in a postmenopausal woman with an ER/PR+, HER2 negative cancer, who is otherwise a candidate for chemotherapy, I will start the endocrine therapy and send OncotypeDX to make sure that we are not leaving out an important part of her management, i.e. ...
In which situations do you offer neoadjuvant chemotherapy for a nodal recurrence alone of ER/PR positive, HER2 negative breast cancer?
There is limited evidence to match this scenario on which to base the decision-making. On the one hand, this is a young woman who now has nodal disease. IF she had presented with this as her original diagnosis, the recommendation would have been for adjuvant chemotherapy followed by endocrine therap...
Does the degree of hormone receptor positivity influence your decision to perform Oncotype testing?
In my clinical practice, the degree of hormone receptor (HR) positivity and the clinical characteristics play an important role in ordering the Oncotype testing for HER2-negative tumors. But for 10 to 100%, if the patient is a candidate for chemo or the patient is willing to use this test as part of...
Would you consider OFS in a young patient (<35) with ER+ breast cancer who required chemotherapy and menses resumed years later while on tamoxifen?
The SOFT/TEXT trial demonstrated a DFS/OS benefit for OFS when added to endocrine therapy. Patients at higher risk (<35 years old, node +, treated with chemotherapy) would likely benefit more. The decision to do this depends on her baseline risk. The HER2 status is interesting in that HER2- patients...
For premenopausal patients with early stage HR+ breast cancer for whom you are recommending tamoxifen, how do you select patients for extended endocrine therapy?
For women who remain premenopausal after 5 years of adjuvant tamoxifen, NCCN guidelines recommend "consider tamoxifen for an additional 5 years," or no further therapy. I consider extended use in most of my patients who reach this point, as a combined analysis of the ATLAS and aTTom studies showed t...
Would you recommend extended adjuvant endocrine therapy if a patient tolerated 5 years thus far but Breast Cancer Index (BCI) shows a high risk of recurrence with low likelihood of benefit from extended therapy?
While I occasionally order the BCI assay in my intermediate risk patients (large primary tumor with negative nodes or smaller tumor with limited nodal involvement), I find that I get this concerning result (increased risk of late recurrence but no apparent benefit from extended adjuvant therapy base...
Would you treat a premenopausal woman with T2N0 ER-, PR+ (15-20%), HER2- breast cancer with neoadjuvant chemotherapy like a triple negative breast cancer?
Yes, I would treat this patient with neoadjuvant chemotherapy as I would for a "triple-negative" breast cancer as certainly the biopsy of an ER 0%, weakly PR positive tumor is similar. I would not send an OncoType on this tumor - if it was low or intermediate, I still would not trust this patient wo...