Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How long would you continue trastuzumab and pertuzumab in a patient with ER+ HER2+ breast cancer with initially osseous involvement treated with ACT-HP and is now in CR by PET for >2 years?
All physicians who treat metastatic HER2 breast cancer eventually have patients who appear to have been "cured" of their metastatic disease with available agents. This question crops up from time to time, wondering if there is some measure of time or test we can use to determine when it would be rea...
How do you manage HR+HER2 negative ILC metastatic recurrence in a post-menopausal woman with extensive GI involvement complicated by a small bowel obstruction?
I think the answer to this question depends on a few factors. The management and outcome of patients with malignant bowel obstruction is described quite well by Tuca et al., PMID 22904637. The type of therapy I try would be influenced by their overall condition. Certainly, I would consider this an "...
Would you consider de-escalating treatment to endocrine therapy alone in a patient with prolonged NED on CDK 4/6 inhibitor + endocrine therapy?
Be good to know more specifics about her breast cancer history, whether this is administered as a first line in an endocrine sensitive setting versus not. If her history is in line with endocrine sensitivity, I think it would be reasonable to de-escalate her treatment to endocrine therapy alone and ...
How would you manage subsequent treatment for a patient with metastatic ER+HER2- breast cancer that develops pneumonitis on a CDK4/6 inhibitor but had an excellent response to therapy?
One of our fellows and I conducted a lit search on this topic several months ago, and then again (briefly) today. There is not much literature to support evidence-based decision making, as the 3 available CDK4/6 inhibitors (palbociclib, abemacicilib, and ribociclib) all have pneumonitis as a reporte...
For a patient with metastatic HR positive breast cancer presenting with spinal cord compression but no visceral metastases, what is your recommended first line systemic therapy?
If it is a de-novo metastatic breast cancer, I would start systemic therapy with AI/fulvestrant or CDk4-6/fulvestrant combo. I have a similar patient who has had a long clinical course with only recurrent spinal metastasis leading to cord compression. No visceral metastasis. Monitor with spine MRI p...
How do you treat leptomeningeal disease in metastatic HR+ HER2- breast cancer?
Survival after a diagnosis of leptomeningeal metastasis (LM) remains poor. Radiation therapy remains a primary therapy for breast cancer LM. Intrathecal therapy has resulted in limited efficacy and is associated with significant toxicity. Limited data regarding the efficacy of systemic therapies in ...
Would you consider a treatment holiday in a patient with HR+ oligometastatic breast cancer who is in a prolonged remission?
Obviously, we have little data to guide our approach here. However, I would feel a bit uncomfortable holding the patient's AI but would consider it in certain situations, such as the patient having toxicities that are difficult to tolerate. In that situation, I would consider an alternative endocrin...
Do you prefer CDK 4/6 inhibitor or PARP inhibitor as first line treatment in a patient with HR+/HER2 neg relapsed/metastatic BRCA positive breast cancer who had previous adjuvant chemotherapy and developed metastatic recurrence while on AI?
PARP inhibitors haven’t been compared head-to-head with CDK4/6 inhibitors in combination with endocrine therapy, but I would start with the CDK4/6 inhibitor + fulvestrant and save the PARP inhibitor for second line. If the patient has brain metastases, I would use the PARP inhibitor instead. If I ha...
Would you consider AI alone over CDK4/6 inhibitor combinations in older patients with breast cancer considering the subgroup analyses from MONALEESA-2 suggest less benefit in patients over 65?
In MONALEESA-2, 295 patients (44%) were ≥ 65 years of age, 150 were randomized to ribociclib + letrozole; and 145 received placebo + letrozole. 370 patients were <65 years of age, 184 were randomized to the ribociclib group, and 186 to the placebo group. The baseline characteristics were balanced be...
How do you approach systemic treatment for intracranial only brain metastases for ER positive, PR negative, HER2 negative breast cancer after stereotactic radiosurgery for brain metastases with negative PET imaging?
Assuming the patient's treatment history doesn't suggest resistance, I would treat the patient with endocrine therapy plus abemaciclib along with regular brain MRI monitoring.