Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does the magnitude of OncoType recurrence score above 26 inform decision between TC and AC/T in ER+ HER2- 1-3 node positive, postmenopausal patients with breast cancer?
We don't have any evidence for correlating recurrence score with choice of chemotherapy. Based on RxPONDER, we know that patients with 1-3 positive lymph nodes and scores less than 25, do not benefit from chemotherapy. Based on retrospective data, we have enough evidence that scores more than 30 wou...
Would you offer adjuvant abemaciclib to young, premenopausal women desiring more children who meet criteria for the same based on monarchE trial?
Based on the package insert for abemaciclib, there is no reported risk of early menopause or amenorrhea. CDK4/6 inhibitors are cytostatic (by blocking the transition from G1 to S phase) and not cytotoxic, unlike alkylating chemotherapy. So, I would feel comfortable offering abemaciclib and subsequen...
How would you approach a post-menopausal women with recurrent ER/PR+, HER2- breast cancer only in the axillary lymph nodes?
This sounds so characteristic of a low-grade ER+ tumor in an elderly lady. I would only resect and confirm at resection the above-suspected pathology. Clearly given her age indolent behavior, local recurrence and low volume I would not torture this elderly lady with nothing more than an AI. The prob...
Would you consider adding neoadjuvant endocrine therapy in a patient with HR+, HER2- breast cancer who has not clinically responded to neoadjuvant chemotherapy?
Generally no, unless conversion to lumpectomy is a goal. If the patient is not a lumpectomy candidate, then I would move on with surgery. Pathological complete responses are low (10%) in ER+ive cancers, thus it is not unusual to see a modest clinical response with chemotherapy.
How do you approach discussion of adjuvant chemotherapy for a T1b (0.5 cm) hormone positive breast cancer with high risk features and an Oncotype Score of 31?
The best available data suggests that the relative benefit of chemotherapy predicted by gene profiling scores is seen across anatomic stages, but the absolute differences in smaller size node negative tumors will of course be smaller, even with a higher Oncotype Dx score. While precise estimates are...
How would you approach a postmenopausal woman with Stage I HR+,HER2- breast cancer who had a CVA while on tamoxifen?
A major co-morbidity such as a stroke should prompt a re evaluation of the benefit risk ratio and overall value of adjuvant endocrine therapy, especially for low risk disease. It would be helpful to unpack this situation a little more. How bad is the stroke and how much loss of mobility and performa...
How would you counsel a patient with HR+, HER2- breast cancer with an OncotypeDx ROR score of 0 who is refusing endocrine therapy?
This is often a challenging case to discuss with patients. Although we know that this patient's likelihood of distant recurrence is very low if she takes 5 years of adjuvant endocrine therapy, we don't actually know what her risk of recurrence is with no systemic therapy. Presumably, those with very...
Would you treat a postmenopausal women with high grade T2N0 ER-, PR+, HER2- invasive ductal carcinoma with upfront surgery or neoadjuvant chemotherapy?
I'd conduct a conversation about NAC, but it isn't clear to me that NAC would change anything for this patient. PR 45% does not qualify as "functionally triple negative" in my book, so I'd consider this still HR+. I would not offer more than AC-T whether NAC or adjuvant. Additionally, I wouldn't off...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
Would you use OncoType in a postmenopausal female with HR+/HER2- with LN involvement who clinically meets RxPONDER criteria of 1-3 LN to guide the use of neoadjuvant chemotherapy?
Yes. If I am asked to consider neoadjuvant therapy in a postmenopausal woman with an ER/PR+, HER2 negative cancer, who is otherwise a candidate for chemotherapy, I will start the endocrine therapy and send OncotypeDX to make sure that we are not leaving out an important part of her management, i.e. ...