Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In which situations do you offer neoadjuvant chemotherapy for a nodal recurrence alone of ER/PR positive, HER2 negative breast cancer?
There is limited evidence to match this scenario on which to base the decision-making. On the one hand, this is a young woman who now has nodal disease. IF she had presented with this as her original diagnosis, the recommendation would have been for adjuvant chemotherapy followed by endocrine therap...
Does the degree of hormone receptor positivity influence your decision to perform Oncotype testing?
In my clinical practice, the degree of hormone receptor (HR) positivity and the clinical characteristics play an important role in ordering the Oncotype testing for HER2-negative tumors. But for 10 to 100%, if the patient is a candidate for chemo or the patient is willing to use this test as part of...
Would you consider OFS in a young patient (<35) with ER+ breast cancer who required chemotherapy and menses resumed years later while on tamoxifen?
The SOFT/TEXT trial demonstrated a DFS/OS benefit for OFS when added to endocrine therapy. Patients at higher risk (<35 years old, node +, treated with chemotherapy) would likely benefit more. The decision to do this depends on her baseline risk. The HER2 status is interesting in that HER2- patients...
For premenopausal patients with early stage HR+ breast cancer for whom you are recommending tamoxifen, how do you select patients for extended endocrine therapy?
For women who remain premenopausal after 5 years of adjuvant tamoxifen, NCCN guidelines recommend "consider tamoxifen for an additional 5 years," or no further therapy. I consider extended use in most of my patients who reach this point, as a combined analysis of the ATLAS and aTTom studies showed t...
Would you recommend extended adjuvant endocrine therapy if a patient tolerated 5 years thus far but Breast Cancer Index (BCI) shows a high risk of recurrence with low likelihood of benefit from extended therapy?
While I occasionally order the BCI assay in my intermediate risk patients (large primary tumor with negative nodes or smaller tumor with limited nodal involvement), I find that I get this concerning result (increased risk of late recurrence but no apparent benefit from extended adjuvant therapy base...
Would you treat a premenopausal woman with T2N0 ER-, PR+ (15-20%), HER2- breast cancer with neoadjuvant chemotherapy like a triple negative breast cancer?
Yes, I would treat this patient with neoadjuvant chemotherapy as I would for a "triple-negative" breast cancer as certainly the biopsy of an ER 0%, weakly PR positive tumor is similar. I would not send an OncoType on this tumor - if it was low or intermediate, I still would not trust this patient wo...
How would you manage an elderly patient with clinical stage IIIC ER positive breast cancer who refuses surgery, chemo and radiation treatment and willing to take only oral medications?
My approach would be to start the patient on an aromatase inhibitor. Since this treatment would not be considered curable and treatment goal would be palliative, a case can be made for consideration of adding CDK 4/6 inhibitor, especially if her disease is considered inoperable due to advance stage.
What is your approach to tamoxifen use in women who are unable to discontinue a strong CYP2D6 inhibitor and who are unable to use or tolerate an AI?
I ran into this very situation not too long ago. In dealing with the situation, I asked myself the following questions: 1) Did I speak to prescribing psychiatrist or psychopharmacologist (or if I was the prescriber or primary care provider refer to a more experienced physician?) 2) Did I do everythi...
What adjuvant chemotherapy would you recommend in a premenopausal patient with pT1cN1 HR+ breast cancer who previously received an anthracycline and cyclophosphamide 30 years prior?
I would defer anthracycline regimens since the risk of cardiomyopathy increases after cumulative dose doxorubicin exceeds 400-450 mg/m2. Her prior exposure to alkylating agents also puts her at risk for secondary MDS from cyclophosphamide which is pretty much present in all modern chemotherapy regim...
What is your approach to chemoprevention for HR+ DCIS in the ipsilateral breast in a patient who already completed 7 years of an AI for a prior HR+ invasive breast cancer?
This is a not-uncommon scenario. What is the appropriate use of endocrine therapy after ipsilateral breast tumor recurrence or second primary breast cancer in a patient who has recently completed hormonal therapy?As shown in the Breast Cancer Prevention Trial (P-1), MAP.3, and IBIS II, both SERMs an...