Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you select your first-line endocrine therapy to accompany CDK4/6 inhibitor in metastatic HR+ breast cancer?
If this is a denovo metastatic patient, my choice of endocrine therapy backbone will be an aromatase inhibitor. If the patient develops metastatic disease while on an AI, or within 6-12 months after completing or discontinuing an AI, I will consider fulvestrant. If there is evidence of an ESR1 mutat...
How does your treatment approach vary in patients with HR+/HER2- breast cancer presenting with CNS metastases?
There are preclinical studies published about ribociclib entering the CNS (Patel et al., PMID 31079218), as well as some clinical studies in non-breast tumors such as meningiomas (Sanai et al., ESMO 2019). However, I am not aware of any published studies in ribociclib analogous to the Phase 2 trial ...
In light of RIGHT Choice trial data, when will you opt for a CDK 4/6 inhibitor plus AI instead of chemotherapy in patients with metastatic HR-positive HER2-negative breast cancer with visceral crisis?
I think it is very reassuring to see that ribociclib + ET led to similar (or better) overall response rates than combination chemotherapy in the RIGHT choice trial presented at SABCS 2022. However, it is incredibly important to keep in mind that the definition of "impending visceral compromise" or "...
What first line therapy would you give a premenopausal patient with HER-2 positive and ER positive metastatic breast cancer with visceral organ involvement?
This is a very good question. In the recently published SYSUCC-002 trial, trastuzumab plus endocrine therapy (ET) was not inferior to trastuzumab plus chemotherapy (CT) as first-line therapy for hormone receptor positive, HER2 positive, metastatic breast cancer. In this trial, 30% of patients were p...
Do you feel comfortable using ribociclib in a patient with metastatic ER+/HER2+ breast cancer who has borderline systolic heart failure from previous HER2 based treatment?
My short answer to the question is, yes, I would feel comfortable treating a metastatic breast cancer with ribociclib despite the presence of borderline CHF related to prior anti-HER-2 therapy. As always, in the treatment of metastatic breast cancer, decisions regarding treatment typically come down...
What is your approach to treatment in hormone receptor positive, HER2 negative (0 IHC) metastatic breast cancer with ERBB2 gene amplification after progression on AI and fulvestrant CDK4/6i with visceral crisis?
More information will be helpful in approaching this case. Was this a de novo presentation or a recurrence case? Was the ERBB2 IHC done on the primary tumor or a metastatic lesion? Was the ERBB2 amplification detected in tissue (primary or metastatic)? At what point in time was this tested (upon ...
Would you still offer trastuzumab deruxtecan in a patient with progressive HR+/HER2+ breast cancer who has prior history of cell cycle inhibitor related pneumonitis?
In DESTINY-Breast04, about 70% of patients were CDK4/6i treated but were excluded if they had a history of ILD/pneumonitis. So, we don't know if this patient is at higher risk of pneumonitis with trastuzumab deruxtecan. I would consider it if her previous pneumonitis was mild and fully resolved with...
Do you recommend the use of elacestrant after prior fulvestrant in metastatic hormone positive breast cancer?
I can think of two ways to answer this question. First, the FDA indication for elacestrant follows the design of the phase III EMERALD trial (Bidard et al., PMID 35584336). The EMERALD trial permitted patients with prior disease progression on one or two prior lines of endocrine therapy (up to 1 lin...
How should we think about endocrine resistance in patients with inherited germline mutations such as BRCA, CHEK2, etc.?
In patients with germline mutations such as BRCA1/2, we have learned that the use of CDK4/6 inhibitors may have less of an impact, suggesting some degree of inherent endocrine therapy resistance. In one retrospective analysis of patients with germline mutations in homologous recombination repair (su...
How do you define PIK3CA/AKT/PTEN alteration for capivasertib use?
For CAPItello-291, tumors had to have activating mutations in PIK3CA or AKT or inactivating alterations in PTEN genes – i.e., genes that were altered/not normal. Gene amplification refers to an increase in the number of copies of the same, normal gene, not an increased rate of transcription. So, PIK...