Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
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...
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...
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.
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 ...
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. ...
For a post-menopausal patient with a pT2N0 HR+/HER2- breast cancer at surgery after 4 months of neoadjuvant anastrozole with minimal clinical or pathologic response, would you utilize genomic testing to guide decision about adjuvant chemotherapy?
This is a very relevant question as we are treating more patients with neoadjuvant endocrine therapy in the COVID-19 era. Ki67 and other markers can respond promptly after neoadjuvant hormonal therapy, it may take longer than 4 months to judge the clinical and histological response. If this is a pat...
Would you offer adjuvant chemotherapy for 1-3 node positive HR+, HER2 negative breast cancer with Mammaprint low risk to a young, pre-menopausal patient?
Until we have the results from the RxPONDER trial (which used Oncotype, not Mammaprint, but addresses this question more directly than MINDACT), we cannot rule out a potential benefit from adjuvant chemotherapy in node-positive patients like these, and thus, I would offer it while saying that the be...
When would you offer ovarian suppression in addition to endocrine therapy for premenopausal women who omit adjuvant chemotherapy?
If a premenopausal woman has a hormone receptor positive breast cancer for which chemotherapy is recommended, but chooses to omit the chemotherapy, I would recommend ovarian suppression or oophorectomy in addition to endocrine therapy. I also typically describe the added benefits of ovarian suppress...