Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you hold endocrine therapy during adjuvant breast radiotherapy?
I start endocrine therapy after RT. For one, I don’t think there is a rush to get endocrine therapy going and would rather focus on the patient being able to tolerate it for the long term. And two, if radiation works best on quickly dividing cells, I don’t want to stunt their proliferation (which we...
What adjuvant therapy would you recommend for a premenopausal woman with low ER+/PR+ (1-10%) HER2- pT1cN0 metaplastic breast cancer?
The rarity of the metaplastic subtype of breast cancer makes it difficult to provide an evidence-based answer regarding what is the "best" adjuvant treatment. About 70% of metaplastic tumors are TNBC and ER-low is a small subset of the remaining 20% with an ER+ epithelial component. In general, some...
Can you use Oncotype for determining adjuvant therapy in a young, premenopausal woman with multifocal HR+ breast cancer s/p mastectomy with 2 positive lymph nodes?
There are no data yet that I am aware of (retrospective or prospective) for the use of Oncotype 21 gene assay to make treatment decisions in premenopausal women with node positive, estrogen receptor positive early stage breast cancer. The prospective RxPONDER trial will hopefully provide data on the...
In a patient with resected ER+ HER2- breast cancer, how do you decide between TC vs ddAC-T for adjuvant chemotherapy?
I seldom (if ever) use the docetaxel/cyclophosphamide regimen. I find it more toxic than DD-AC-T, so I tend to use the latter once I determine that chemotherapy is indicated. Perhaps a more fundamental question for these patients is which needs or is likely to benefit from chemotherapy. If I have an...
Do you use platinum therapy in BRCA1 mutated patients with ER/PR positive disease receiving neoadjuvant chemotherapy?
In the absence of any data (of which I am aware) of benefit from adding a platinum analog to neoadjuvant chemotherapy in BRCA1-mutated patients with ER-positive/HER2-negative cancers (other than those with minimal ER expression, whom I treat as I do patients with triple-negative cancers, with the ad...
How do you approach recommending tamoxifen in a premenopausal woman with Li Fraumeni syndrome and early stage low risk ER+ breast cancer?
The risk of uterine sarcoma is 17 per 100,000 patients per year on tamoxifen which is higher than the average population, i.e., 2 per 100,000 patients per year. The lifetime risk of soft tissue sarcoma in Li Fraumeni Syndrome (LFS) female patients is about 15%. In a series of 64 LFS breast cancer pa...
Are pre-menopausal women on tamoxifen at risk for endometrial cancer?
Analysis of endometrial cancer rates in the NSABP P1 trial in women under age 50, demonstrated a relative risk of 1.42 (0.55-3.81) for tamoxifen that was not statistically significant. Per 1000 women, the rates were 0.82 for placebo and 1.16 for tamoxifen. (Fisher et al., PMID 16288118)
How do you approach recurrent, localized HR+, HER2- breast cancer in a patient who has progressed on exemestane (and previously on letrozole and tamoxifen)?
If the tumor is not resectable, I would use fulvestrant and a CDK inhibitor; but if the ER/PR expression is low, I might consider pre-operative chemotherapy using a standard adjuvant chemotherapy regimen—most likely AC-T. If the tumor is resectable (or has been resected), then I would use adjuvant c...
In light of RxPonder results for postmenopausal women with early stage node positive HR+HER2- breast cancer, when is there a role for full axillary LN dissection to confirm degree of nodal involvement and when would sentinel LN evaluation be sufficient?
I don’t think the RxPonder study changes surgical management. Still follow Z0011 paradigm.
Do you need to wait for estradiol and FSH levels to normalize before you can switch from tamoxifen to an AI for a pre-menopausal woman with ER+ breast cancer?
Since tamoxifen can also affect hormone levels, it is prudent to hold tamoxifen for a month before checking hormone levels. In this case, it is reasonable to stop tamoxifen due to endometrial thickening. One could consider checking hormone levels after a month of stopping tamoxifen and if they are i...