Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer local therapy with either SBRT or Y-90 in a patient with metastatic ER+ HER2 low breast cancer with two oligometastatic liver lesions currently on AI + CDK4/6 inhibitor?
No.Longer answer:I acknowledge that controlling liver disease improves outcomes in metastatic cancer (including breast, and including y-90 for breast Barakat et al., PMID 35071835). However, it depends on how and when you use the tool. My reason for saying no in this setting: this is a patient with ...
Is there a clinically significant increased risk of venous thromboembolism with the use of fulvestrant for metastatic HR+ breast cancer?
The reason for VTE? Post-operative, trauma, hypercoagulability due to having cancer or its treatment, hereditary hypercoagulability, or idiopathic? I am going to assume that the VTE was self-limited and treated with a course of anticoagulation. Does fulvestrant cause VTE? Ideally, a randomized place...
What is the optimal sequence of systemic therapy for a patient with HR+, gBRCA mutated metastatic breast cancer?
The optimal sequencing of HR positive and BRCA germline positive patients has not been established yet in prospective trials. Studies evaluating PARP inhibitors (either single agent or in combination with chemotherapy) versus chemotherapy included patients with HR positive disease, many of whom rece...
How do you select systemic therapy for recurrent HR+ HER2 negative breast cancer in the bones in a premenopausal woman within a year of starting adjuvant AI with OFS plus abemaciclib and zoledronic acid?
This is, unfortunately, a case of primary endocrine resistance, and recurrence on adjuvant Abemaciclib makes the case more challenging for this pre-menopausal patient.It would be reasonable to repeat tissue biopsy to rule out a change in hormone receptor status and consider blood based ctDNA analysi...
How would you treat a newly metastatic ER+ PR+ HER2+ triple positive breast cancer with diffuse symptomatic disease and severe neuropathy from prior adjuvant paclitaxel?
This is a challenging clinical situation where the medical oncologist has to balance the need to rapidly induce a response to relieve the patient's symptoms and the risk of exacerbating the patient's peripheral neuropathy, which may be irreversible. Because of the latter concern, I would avoid stand...
How do you decide among approved CDK4/6 inhibitors for first line treatment of patients with metastatic HR+ breast cancer now that OS analyses are available in MONALEESA-2, MONARCH-3 and PALOMA-2?
Updated Answer 1/23/24: I was asked to update my prior answer in light of final OS results from the MONARCH 3 trial, which read out at SABCS, and comment on whether this would impact my treatment selection. While MONARCH-3 did not show a statistically significant OS benefit, the difference in OS b...
How do you select your first-line endocrine therapy to accompany CDK4/6 inhibitor in metastatic HR+ breast cancer?
If this is a denovo metastatic patient, my choice of endocrine therapy backbone will be an aromatase inhibitor. If the patient develops metastatic disease while on an AI, or within 6-12 months after completing or discontinuing an AI, I will consider fulvestrant. If there is evidence of an ESR1 mutat...
How does your treatment approach vary in patients with HR+/HER2- breast cancer presenting with CNS metastases?
There are preclinical studies published about ribociclib entering the CNS (Patel et al., PMID 31079218), as well as some clinical studies in non-breast tumors such as meningiomas (Sanai et al., ESMO 2019). However, I am not aware of any published studies in ribociclib analogous to the Phase 2 trial ...
In light of RIGHT Choice trial data, when will you opt for a CDK 4/6 inhibitor plus AI instead of chemotherapy in patients with metastatic HR-positive HER2-negative breast cancer with visceral crisis?
I think it is very reassuring to see that ribociclib + ET led to similar (or better) overall response rates than combination chemotherapy in the RIGHT choice trial presented at SABCS 2022. However, it is incredibly important to keep in mind that the definition of "impending visceral compromise" or "...
What first line therapy would you give a premenopausal patient with HER-2 positive and ER positive metastatic breast cancer with visceral organ involvement?
This is a very good question. In the recently published SYSUCC-002 trial, trastuzumab plus endocrine therapy (ET) was not inferior to trastuzumab plus chemotherapy (CT) as first-line therapy for hormone receptor positive, HER2 positive, metastatic breast cancer. In this trial, 30% of patients were p...