Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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.
For patients with metastatic HER2-null breast cancer, do you offer trastuzumab deruxtecan based on the DAISY trial results?
DAISY trial was a small trial and the outcome was hypothesis-generating rather than practice-changing. With that said, I offer trastuzumab deruxtecan to patients with metastatic breast cancer even if HER2 IHC on biopsy of metastatic disease was 0 but historically, their primary tumor tested at least...
Would you start fulvestrant plus CDK4/6 inhibitors in a patient with ESR1 mutation with metastatic breast cancer on liquid biopsy in a first-line setting?
Since the presence of ESR1 mutation is associated with a lack of benefit from aromatase inhibitors, I tend to start patients who have evidence of this mutation on fulvestrant in combination with a CDK 4/6 inhibitor (typically ribociclib). ESR1 mutation found on circulating tumor DNA suggests that a ...
How would you treat a patient with symptomatic and rapidly progressing metastatic HR+, HER2 low breast cancer with PIK3CA WT, ESR1 mutated, TMB high after progression on CDK 4/6 inhibitor, a taxane, and T-DXd?
With disease progressing on increasing number of systemic therapy lines, the likelihood of having a response diminishes. In the absence of an impending organ crisis, one could consider fulvestrant with alpelisib, elacestrant, or pembrolizumab. However, if the patient is facing an impending organ fai...
What is your preferred first line therapy for metastatic HR+ inflammatory breast cancer?
Data for non-IBC metastatic HR+ breast cancer has demonstrated excellent efficacy of endocrine-based therapy in the 1st line setting allowing delay of chemotherapy until later lines. However, IBC behaves very differently than non-IBC and tends to be higher grade with more endocrine resistance. Given...
What disease characteristics will guide your choice of alpelisib plus fulvestrant (per SOLAR-1) versus capivasertib plus fulvestrant (per CAPItello-291) in PIK3CA mutated advanced ER+/HER2- breast cancer after progression on 1L ET regimen, given both are now approved in this population?
In the absence of head-to-head comparison, I would use cross-trial comparison to compare the efficacy and safety of alpelisib vs capivasertib. mPFS are similar for both: HR 0.65 (11 vs 5.7 months) for alpelisib (SOLAR-1); and mPFS HR 0.6 (7.2 vs 3.6 months) for capivasertib (CAPItello-291). Therefor...
Would you offer capivasertib+fulvestrant in a patient with metastatic HR+ HER2 negative breast cancer with PTEN mutation who has progressed on fulvestrant plus ribociclib?
Strictly speaking, prior fulvestrant was not allowed in CAPItello-291. Also, only 5% of patients in CAPItello-291 had PTEN gene alterations assessed by NGS. With that said, if there were no other targeted non-chemo options, I may consider it. This is an extrapolation from a small retrospective study...