Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach adjuvant systemic therapy for a pT3N0(i+) HR+/HER2 negative breast cancer with an intermediate oncotype in a post-menopausal woman?
This is a great question that I ponder a lot. I've asked countless colleagues informally "what's the largest tumor you'll trust oncotype on"? The only true “prediction” data we have comes from the original B-20 trial, which included T3 tumors. Although the publication only breaks out tumor size as >...
How would you manage a premenopausal woman with a poorly differentiated pT2 HR+/HER2- breast cancer and 3/3 SLNs with ITCs?
Assuming she was clinically N0 prior to surgery, I would not subject her to an ALND but would favor axillary radiation; since ITC is not considered 'node-positive' she doesn't meet criteria for the AMAROS trial but I would extrapolate the equivalence of axillary radiation to ALND from that study to ...
What adjuvant therapy would you recommend for a premenopausal patient with ER/PR+, HER2 negative T2N0 breast cancer s/p mastectomy, low OncotypeDx score and in first trimester of pregnancy?
If the RS is very low, then I would not recommend chemotherapy.
Based on the results of MonarchE, would you offer adjuvant abemaciclib for HR+ patients who do not achieve pCR after neoadjuvant chemotherapy?
I would not offer abemaciclib for many reasons, especially under the premise in the question that pathologic complete response is the right endpoint for ER+ breast cancer. This is a disease biology that is driven by proliferation over many years and has a very low rate of path CR, to begin with. Esp...
How do recent RxPonder results affect your adjuvant therapy choice for premenopausal women with HR+/HER2 negative breast cancer with 1-3 positive LNs?
In the RxPONDER clinical trial, all premenopausal patients with HR+ HER2-negative breast cancer with 1-3 positive LNs had a benefit from adjuvant chemotherapy regardless of their Oncotype DX RS. Therefore, there would not be a need to send for an Oncotype or Mammaprint. This management would not cha...
For anatomic stage III ER/PR+ breast cancer treated upfront with surgery, how do you decide which adjuvant chemotherapy to offer?
Anatomic stage III breast cancer includes different clinical scenarios ranging from a tumor over 5cm with 1-3 + lymph nodes, tumors with 4 or more + lymph nodes, tumors with chest wall/skin invasion, and inflammatory breast cancer. For the first scenario, a T3N1 post menopausal female with an Oncoty...
What endocrine therapy would you recommend for a perimenopausal female with a low risk Oncotype, HR+, HER2-negative, SLNB negative breast cancer who is clinically postmenopausal but with FSH, LH and estradiol that are not in the postmenopausal range?
In this situation, with a low risk, node-negative disease with ambivalent menopausal status, Tamoxifen, unless contraindicated, would be my choice. A SERM is equally effective for premenopausal and postmenopausal women. In the course of adjuvant endocrine therapy, changing to an aromatase inhibitor ...
How do you approach treatment in premenopausal patients who develop a contralateral HR+ breast cancer while already on tamoxifen and ovarian function suppression?
Several pieces of information are lacking in this clinical case to make a solid treatment recommendation: what is the current age of the patient? What is her menopausal status? Is the new contralateral breast cancer clinically node negative? Since this new second primary contralateral breast cancer ...
What adjuvant therapy would you offer an elderly but healthy patient with T2N1 HR+ HER2+ breast cancer who is not willing to receive cytotoxic chemotherapy?
The Japanese RESPECT trial (Sawaki et al., PMID 32936713) compared trastuzumab alone (T) vs chemo+trastuzumab (Ch+T) in patients >=70 and demonstrated a 3 year DFS of 89.5% (T) vs 93.8% (Ch+T) HR 1.31 p=.51. Based on this data, you could discuss adjuvant AI+trastuzumab for 1 year.
How would you treat a post-menopausal woman found to have a node-negative ipsilateral HR+ breast cancer recurrence with pectoral muscle invasion following a prior mastectomy, radiation, and AI therapy completed > 5 years ago?
I would probably give "neoadjuvant" therapy... according to the age of the patients, comorbidities, prior exposure to chemo in the past, and biology of the HR+/HER2-, I would choose between neoadjuvant chemotherapy or neoadjuvant endocrine therapy (with or without a CDK 4/6 inhibitor).