Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
How would you manage adjuvant endocrine therapy for a postmenopausal patient with early stage HR+ breast CA who develops an ischemic CVA on an AI?
This is a vexing problem that I myself have had to deal with. My patient developed a TIA on aromatase inhibitor (AI). Work up was negative for predisposing risk factors. The choice was easy in this case. This woman was told by her family friend, who was a doctor, that AIs cause stroke and she refuse...
Would you use OncoType Dx to guide adjuvant therapy recommendations in the context of locally recurrent, node-negative, ER+ breast cancer previously treated with endocrine therapy alone?
Assuming that 1.) the recurrence is in ipsilateral breast tissue post-radiation therapy, 2.) the patient is on adjuvant hormone therapy, and 3.) the pathologist concurs that this is not a new primary, we could approach this problem on multiple fronts.1.) Does the tumor harbor an ESR1 mutation? Altho...
How do you plan to use adjuvant denosumab in patients with hormone positive breast cancer given the survival advantage seen in the ABCSG-18 trial?
Both adjuvant denosumab at 60 mg SQ every 6 months and adjuvant zoledronic acid at 4 mg IV every 6 months are reasonable options to consider as part of adjuvant treatment in post-menopausal women and both have prospective data to show statistically significant but very small improvements in disease ...
How strict are you about adhering to the eligibility criteria required for entry onto the OlympiA trial in considering a year of adjuvant olaparib as adjuvant therapy for BRCA mutated, node positive, ER positive breast cancer?
When considering PARP inhibitors or CDK4/6 inhibitors in the adjuvant setting, we follow the criteria used for the trials. This is because the trials dictated what is now in the guidelines and the guidelines dictate what insurance will cover.
What alternate neo-adjuvant backbone chemotherapy would you recommend in a patient with ER+ HER2+ clinical stage II breast CA with severe pan-colitis following a cycle of TCHP with docetaxel?
I would switch to weekly paclitaxel and carboplatin with trastuzumab only, but might retry pertuzumab if the patient gets through 6 weeks without recurrent diarrhea. This is actually my preferred version of TCHP (including the pertuzumab), which I find to be better tolerated than the every-3-week do...
What is your cut off on ER percent positivity to treat breast cancer as functional triple negative cancer?
I usually use less than 10% ER positivity as the cut off. In this case, I would treat as if the tumor is TNBC.
Do you modify your choice of systemic therapy for localized early stage ER+/PR+ HER2- breast if Mammaprint shows basal subtype?
It would make me want to recheck the ER/PR IHC through another lab to make sure it is truly positive. There are some ER positive tumors (especially low expressors) that have basal transcriptional profiles suggesting a lack of estrogen pathway signaling. If the ER is truly positive and it is >= 10% o...
How do you interpret the EBCTCG meta-analysis analyzing the magnitude of benefit of anthracyclines in early stage ER+ breast cancer?
The appreciation of studies testing the specific benefit of adding or substituting anthracyclines as adjuvant therapy for early stage breast cancer requires a historical overview (so my apologies for a very long response….). Several of the earlier trials comparing non-anthracycline therapies (primar...
Would you give adjuvant endocrine therapy to a premenopausal woman with early stage node positive breast cancer that was ER negative, PR positive (60%) and HER2 positive?
The first thing I would do in this case is have the block retested for ER staining preferably at a different lab. There have been multiple studies published in the past that have shown ER negative PR positive tumors (particularly strong PR staining like this one) frequently end up being ER+ on retes...