Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you start fulvestrant plus CDK4/6 inhibitors in a patient with ESR1 mutation with metastatic breast cancer on liquid biopsy in a first-line setting?
Since the presence of ESR1 mutation is associated with a lack of benefit from aromatase inhibitors, I tend to start patients who have evidence of this mutation on fulvestrant in combination with a CDK 4/6 inhibitor (typically ribociclib). ESR1 mutation found on circulating tumor DNA suggests that a ...
How would you treat a patient with symptomatic and rapidly progressing metastatic HR+, HER2 low breast cancer with PIK3CA WT, ESR1 mutated, TMB high after progression on CDK 4/6 inhibitor, a taxane, and T-DXd?
With disease progressing on increasing number of systemic therapy lines, the likelihood of having a response diminishes. In the absence of an impending organ crisis, one could consider fulvestrant with alpelisib, elacestrant, or pembrolizumab. However, if the patient is facing an impending organ fai...
What is your preferred first line therapy for metastatic HR+ inflammatory breast cancer?
Data for non-IBC metastatic HR+ breast cancer has demonstrated excellent efficacy of endocrine-based therapy in the 1st line setting allowing delay of chemotherapy until later lines. However, IBC behaves very differently than non-IBC and tends to be higher grade with more endocrine resistance. Given...
Would you offer capivasertib+fulvestrant in a patient with metastatic HR+ HER2 negative breast cancer with PTEN mutation who has progressed on fulvestrant plus ribociclib?
Patients who received prior Faslodex were excluded from the CAPItello-291 trial. I guess if you're being a purist you'd have to say no. Just thinking out loud: I don't see updated results, but there was a cohort (cohort B) in the BYLieve trial that was studying letrozole + Alpelisib in patients who ...
Would you offer local therapy with either SBRT or Y-90 in a patient with metastatic ER+ HER2 low breast cancer with two oligometastatic liver lesions currently on AI + CDK4/6 inhibitor?
No.Longer answer:I acknowledge that controlling liver disease improves outcomes in metastatic cancer (including breast, and including y-90 for breast Barakat et al., PMID 35071835). However, it depends on how and when you use the tool. My reason for saying no in this setting: this is a patient with ...
What is the optimal sequence of systemic therapy for a patient with HR+, gBRCA mutated metastatic breast cancer?
The optimal sequencing of HR positive and BRCA germline positive patients has not been established yet in prospective trials. Studies evaluating PARP inhibitors (either single agent or in combination with chemotherapy) versus chemotherapy included patients with HR positive disease, many of whom rece...
Is there a clinically significant increased risk of venous thromboembolism with the use of fulvestrant for metastatic HR+ breast cancer?
The reason for VTE? Post-operative, trauma, hypercoagulability due to having cancer or its treatment, hereditary hypercoagulability, or idiopathic? I am going to assume that the VTE was self-limited and treated with a course of anticoagulation. Does fulvestrant cause VTE? Ideally, a randomized place...
How do you select systemic therapy for recurrent HR+ HER2 negative breast cancer in the bones in a premenopausal woman within a year of starting adjuvant AI with OFS plus abemaciclib and zoledronic acid?
This is, unfortunately, a case of primary endocrine resistance, and recurrence on adjuvant Abemaciclib makes the case more challenging for this pre-menopausal patient.It would be reasonable to repeat tissue biopsy to rule out a change in hormone receptor status and consider blood based ctDNA analysi...
How would you treat a newly metastatic ER+ PR+ HER2+ triple positive breast cancer with diffuse symptomatic disease and severe neuropathy from prior adjuvant paclitaxel?
This is a challenging clinical situation where the medical oncologist has to balance the need to rapidly induce a response to relieve the patient's symptoms and the risk of exacerbating the patient's peripheral neuropathy, which may be irreversible. Because of the latter concern, I would avoid stand...
How do you decide among approved CDK4/6 inhibitors for first line treatment of patients with metastatic HR+ breast cancer now that OS analyses are available in MONALEESA-2, MONARCH-3 and PALOMA-2?
Updated Answer 1/23/24: I was asked to update my prior answer in light of final OS results from the MONARCH 3 trial, which read out at SABCS, and comment on whether this would impact my treatment selection. While MONARCH-3 did not show a statistically significant OS benefit, the difference in OS b...