Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adjuvant chemotherapy for a patient with HR+/HER2- breast cancer, luminal type A on Mammaprint, after knowing that the patient had a poor response to neoadjuvant endocrine therapy?
I'm going to assume this is an older patient who is postmenopausal, as current guidelines from ASCO state that neoadjuvant endocrine therapy (NET) should not be offered to premenopausal women.My first question is: which specimen was tested? There was a nice poster looking at gene changes and Mammapr...
How would you approach a patient with ER+,HER2- T4N0 breast cancer with chest wall involvement?
In a patient with locally advanced ER positive HER2 negative breast cancer, requiring neoadjuvant therapy, I would use third generation chemotherapy such as AC followed by paclitaxel (often in a dose dense fashion), as long as there are no contraindication to anthracycline based regimen. This EBCTCG...
How do you approach a post-menopausal female with early stage ER+,HER2+ breast cancer s/p lumpectomy with invasive ductal histology and lymph node involvement with invasive lobular histology?
The discrepancy between histology in the lymph node and breast is concerning for occult invasive lobular carcinoma in the breast. It would be a good idea to obtain second opinion in pathology. If pathology is confirmed, breast MRI could help identify invasive lobular cancer that may not be easily de...
How would you approach a patient with T3 HR+,HER2- breast cancer who had no clinical improvement after ddAC?
This is one of those questions where I wish I had a tiny bit more information about the decision-making behind electing NAC. For instance, was this breast cancer grade 3, with a high Ki-67 and ER 25% PR ngtv? Or was this patient a very borderline candidate for breast-conservation and motivated enoug...
What would you advise a breastfeeding woman with localized HR+ breast cancer in terms of risk of progression with breastfeeding prior to local therapy with surgery?
For every 12 months of breastfeeding, the risk of developing breast cancer is lowered by about 4%. I know of no data that describes increased risks of progression prior to surgery regarding ER-positive breast cancer. However, the breasts are engorged during breastfeeding, and they involute when stop...
Do you consider adjuvant chemotherapy for older women >75 years of age, with HR+ invasive ductal carcinoma and 3 positive LN however intermediate risk recurrence scores?
Until the prospective data from RxPONDER is out, we only have retrospective data for node + disease. Based on the Israeli Registry study, 2-3+ node patients with scores under 18 had a 5-year recurrence rate of 5.4%. For N+ patients, the recurrences were lower for chemo vs no chemo (1% vs 9.7%) in th...
Would you offer adjuvant chemotherapy to a premenopausal patient with ER/PR+ breast cancer, nodal micrometastasis, low OncotypeDx score but also BRCA2 carrier?
A breast cancer developing in a BRCA2 mutation cancer has the same prognosis as a non-mutation carrier (Robson et al., PMID 14680495), I would follow the low Oncotype score (assuming it is not 21-25) and treat her accordingly. If child-bearing is not a concern, and she is over 35 years, then bilater...
How do the new RxPONDER results affect your choice of adjuvant therapy for postmenopausal women with HR+/HER2 negative breast cancer and 1-3 positive lymph nodes?
The RxPonder trial results show that in postmenopausal women with 1-3 positive nodes and recurrence scores under or equal to 25, there was no benefit for chemotherapy added to endocrine therapy versus endocrine therapy alone. Whereas, for those with recurrence of 26 or above, I would offer chemother...
What is your approach to adjuvant hormone therapy for HR+ breast cancer in post-menopausal women with pre-existing osteoporosis?
Pre-existing osteoporosis, I assume secondary causes of osteoporosis and vitamin D3 deficiency have been ruled out, and she is on antiresorptive medications. In this case, I would use tamoxifen. In postmenopausal osteoporosis, tamoxifen mitigates bone loss but does prevent fractures. Suppose there a...
Do you plan to offer adjuvant olaparib to all gBRCA+ breast cancer whether TNBC or HR+?
I offer adjuvant olaparib to germline BRCA mutated breast cancer patients (TNBC or hormone receptor positive and Her-2 negative) only if they meet the inclusion criteria that was used in the OlympiA study, which is as follows:1) Patients with triple-negative breast cancer who were treated with adjuv...