Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adjuvant capecitabine in a premenopausal patient with HR-positive inflammatory breast cancer who had residual disease after neoadjuvant chemotherapy?
Yes, I would consider adjuvant capecitabine for a patient with residual invasive disease after standard neoadjuvant chemotherapy (NAC) for HR+ inflammatory breast cancer. Given the uncertainties about the absolute benefit in recurrence and mortality in this specific situation, I would discuss this w...
How would you approach adjuvant therapy for a young post-menopausal woman with a grade 3 pT1a (5mm) node negative ER+/HER2- invasive ductal carcinoma?
There is no data from the prospective trials to support genomic testing in T1a tumors. TAILORx did not enroll T1a tumors. A G3 tumor under 1cm is clinically low risk so Mammaprint would not have clinical utility either. Since NCCN doesn't recommend chemotherapy in this scenario, I would not test.
How would you council a woman in her 50s with Stage I HR+/HER2- breast cancer with a high risk Mammaprint but intermediate OncotypeDx regarding adjuvant chemotherapy?
This is a challenging question to address without more details. The first question is why were two different assays run on the tumor? Also, in the context of the TAILORx data which demonstrated a lack of benefit from chemotherapy for postmenopausal women with Oncotype DX recurrence scores 25 or less...
In cases in which Oncotype DX test is not available, how do you decide which patients with HR+ and Her2- breast cancer are candidates for adjuvant chemotherapy?
If OncotypeDx is not available for an ER+ Her2- primary breast cancer: In general, there are two main components to the 21 gene assay: proliferative thrust and estrogenic signaling. Thus tumors that have strong staining for ER tend to be driven by estrogenic signaling. This is especially true if th...
Would you consider using OncoType Dx testing in a patient with breast cancer if nodal evaluation is not performed?
In women who are 65 and older who have clinically negative axilla, there are less node assessments done with BCS, given data showing they do not add very much. If the patient is otherwise a candidate for adjuvant chemotherapy, I do check a genomic expression profile, either OncotypeDX or MammaPrint....
Would you still obtain Ki-67 prior to use of adjuvant abemaciclib in a patient who has otherwise met MonarchE treatment criteria, such as 1-3 positive LNs, grade 3 and/or tumor >5 cm?
In the setting of a patient with residual disease after NAT with an initial grade 3 stage IIIA ER positive breast cancer, I would treat with adjuvant abemaciclib regardless of Ki67 status if the absolute risk of recurrence was high enough. pCR rates after NAT for ER positive breast cancer are low, a...
Would you offer OFS/AI alone or with the addition of chemotherapy in a premenopausal female with ER+/PR+ breast cancer with microscopic LN involvement and an OncoTypeDx score <11?
Oncotype recurrence score (RS) testing provides both prognostic and predictive information. This is a tumor with a low score and has an excellent prognosis, regardless of what treatment is given. Chemotherapy would not be necessary in an endocrine-sensitive tumor such as this.The issue, of course, c...
Do you provide prophylactic anticoagulation with abemaciclib in the adjuvant setting given known thrombosis risk?
I don’t generally recommend prophylactic anticoagulation with abema, either in the adjuvant or metastatic setting. There does appear to be a small, but real, incidence of thrombosis associated with abema, as well as the other CDK 4/6 inhibitors. While this risk is quite uncommon, it is important cer...
How do you decide whether to offer tamoxifen or OFS + AI in premenopausal patients with metastatic ER+ HER2+ breast cancer as your endocrine therapy?
In general, for node-positive premenopausal women, I use AI and OS. For node-negative patients, I generally use tam + OS for oncotypes 16-21 (the group where we saw a 2% benefit from chemo in TAILORx) and AI + OS for oncotypes 21-25 (where we saw a 7% benefit from chemo in TAILORx). It seems from SO...
What would be your treatment approach in a premenopausal BRCA2+ patient with cT2N0 grade 2-3, ER negative, PR variably positive (30%; staining weak to high), HER2 negative breast cancer?
Since weakly hormone-positive, HER2-negative breast cancer behaves more similarly to triple-negative breast cancer than strongly hormone receptor-positive breast cancer (Poterala et al., PMID 35676188), I would approach this patient similarly to patients with stage 2 triple-negative breast cancer. I...