Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with early stage HR+ breast cancer who was perimenopausal at diagnosis but intolerant of AI, would you consider extending tamoxifen beyond 10 years?
ATLAS and aTTom trial : - 10 years of extended adjuvant Therapy. In absence of data, I will not extend Adjuvant Therapy.
How would you manage adjuvant therapy for a premenopausal female with a T1cN1mi breast IDC that is HR+ HER2 positive on biopsy, but HR+ HER2 negative on lumpectomy surgical specimen?
Overall, I agree with Dr. @Dr. First Last's response regarding treating this as a heterogenous tumor, but I would probably lean towards 4 cycles of TC (docetaxel/cyclophosphamide) for the HR+/HER2 neg component and then add 1 year of trastuzumab. This would avoid the risks of anthracyclines and pert...
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
How do you approach adjuvant therapy to minimize cardiotoxicity in early stage node negative HER2+ HR+ breast cancer with history of chest wall radiation and previous cardiotoxic agents for Hodgkin Lymphoma?
The recommended adjuvant treatment approach for a middle-aged patient with a history of mantle cell radiation for Hodgkin lymphoma and early-stage node-negative bilateral HER2+ HR+ breast cancer, while minimizing cardio toxicity, involves a multidisciplinary approach. Given the patient's history of...
Would you use aspirin 81 mg for VTE prophylaxis in patients on adjuvant tamoxifen/SERMs?
In a meta-analysis of over 30,000 patients, VTE was found in 2.8% of patients on tamoxifen and 1.6% of patients on AI. So, yes there is a higher risk of VTE on tamoxifen but the percentage is still very low. I would not use 81 mg aspirin as VTE prophylaxis in all patients on tamoxifen to rescue or p...
Does a complete pathologic response to neoadjuvant chemotherapy affect the duration of endocrine therapy/OFS that you recommend for a premenopausal patient with HR+/Her2+ breast cancer?
This is a great question. In my practice, I do not alter duration of endocrine therapy based on response to chemo. Luminal tumors less commonly achieve pCR, and degree of response to neoadjuvant chemotherapy is less reliable as a prognostic factor in luminal tumors compared to TNBC and HER2+ tumors....
Would you consider adjuvant endocrine therapy for DCIS in a patient who received bilateral nipple-sparing mastectomies?
No. This is chemoprophylaxis, and the very small amount of remnant breast tissue does not denote a risk of subsequent breast disease high enough to justify the toxicities and risks of endocrine therapy.
Which chemotherapy is preferred between TC and AC-T in a young patient with ER+/PR+/HER2- node negative breast cancer, intermediate grade, with high OncoType score?
If this patient has a small, node negative, hormone receptor positive, HER2 negative intermediate grade tumor, I would be comfortable with recommending 4 cycles of adjuvant docetaxel and cyclophosphamide. Based on ABC trial results, the groups that benefited from AC-T regimen were patients with high...
How do you approach a pre-menopausal female with HR+ breast cancer with discordant IHC and OncotypeDx ER expression?
There are multiple reasons this can happen. The RNA and protein for ER have different stability in FFPE, heterogeneity between the biopsy sample used for IHC vs the surgically resected tumor used for Oncotype, or a failure to properly amplify the transcript from the sample provided are some causes. ...
How would you approach a postmenopausal female with localized ER+ breast cancer on adjuvant anastrozole with a rising estradiol level?
First, I do not usually check estradiol levels in my patients on an aromatase inhibitor, in part because many of the available estradiol assays are not very accurate, and because the AIs are so effective at blocking estrogen production. However, now that you have this value, the first thing I would ...