Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you feel comfortable using ribociclib in a patient with metastatic ER+/HER2+ breast cancer who has borderline systolic heart failure from previous HER2 based treatment?
My short answer to the question is, yes, I would feel comfortable treating a metastatic breast cancer with ribociclib despite the presence of borderline CHF related to prior anti-HER-2 therapy. As always, in the treatment of metastatic breast cancer, decisions regarding treatment typically come down...
What is your approach to treatment in hormone receptor positive, HER2 negative (0 IHC) metastatic breast cancer with ERBB2 gene amplification after progression on AI and fulvestrant CDK4/6i with visceral crisis?
More information will be helpful in approaching this case. Was this a de novo presentation or a recurrence case? Was the ERBB2 IHC done on the primary tumor or a metastatic lesion? Was the ERBB2 amplification detected in tissue (primary or metastatic)? At what point in time was this tested (upon ...
Would you still offer trastuzumab deruxtecan in a patient with progressive HR+/HER2+ breast cancer who has prior history of cell cycle inhibitor related pneumonitis?
In DESTINY-Breast04, about 70% of patients were CDK4/6i treated but were excluded if they had a history of ILD/pneumonitis. So, we don't know if this patient is at higher risk of pneumonitis with trastuzumab deruxtecan. I would consider it if her previous pneumonitis was mild and fully resolved with...
Do you recommend the use of elacestrant after prior fulvestrant in metastatic hormone positive breast cancer?
I can think of two ways to answer this question. First, the FDA indication for elacestrant follows the design of the phase III EMERALD trial (Bidard et al., PMID 35584336). The EMERALD trial permitted patients with prior disease progression on one or two prior lines of endocrine therapy (up to 1 lin...
How should we think about endocrine resistance in patients with inherited germline mutations such as BRCA, CHEK2, etc.?
In patients with germline mutations such as BRCA1/2, we have learned that the use of CDK4/6 inhibitors may have less of an impact, suggesting some degree of inherent endocrine therapy resistance. In one retrospective analysis of patients with germline mutations in homologous recombination repair (su...
How do you define PIK3CA/AKT/PTEN alteration for capivasertib use?
For CAPItello-291, tumors had to have activating mutations in PIK3CA or AKT or inactivating alterations in PTEN genes – i.e., genes that were altered/not normal. Gene amplification refers to an increase in the number of copies of the same, normal gene, not an increased rate of transcription. So, PIK...
Do you start systemic therapy for patients with previously localized HR+ breast cancer developing solitary bone metastasis which is now triple negative if there are no other sites of disease after metastasis-directed radiation?
I would start chemotherapy because of the triple-negative status of the metastasis. This is a patient who initially presented with hormone receptor-positive breast cancer and subsequently developed an isolated bone metastasis that was triple negative. The question of systemic therapy post-localized ...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669