Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Based on the results of MonarchE, would you offer adjuvant abemaciclib for HR+ patients who do not achieve pCR after neoadjuvant chemotherapy?
I would not offer abemaciclib for many reasons, especially under the premise in the question that pathologic complete response is the right endpoint for ER+ breast cancer. This is a disease biology that is driven by proliferation over many years and has a very low rate of path CR, to begin with. Esp...
How do recent RxPonder results affect your adjuvant therapy choice for premenopausal women with HR+/HER2 negative breast cancer with 1-3 positive LNs?
In the RxPONDER clinical trial, all premenopausal patients with HR+ HER2-negative breast cancer with 1-3 positive LNs had a benefit from adjuvant chemotherapy regardless of their Oncotype DX RS. Therefore, there would not be a need to send for an Oncotype or Mammaprint. This management would not cha...
For anatomic stage III ER/PR+ breast cancer treated upfront with surgery, how do you decide which adjuvant chemotherapy to offer?
Anatomic stage III breast cancer includes different clinical scenarios ranging from a tumor over 5cm with 1-3 + lymph nodes, tumors with 4 or more + lymph nodes, tumors with chest wall/skin invasion, and inflammatory breast cancer. For the first scenario, a T3N1 post menopausal female with an Oncoty...
What endocrine therapy would you recommend for a perimenopausal female with a low risk Oncotype, HR+, HER2-negative, SLNB negative breast cancer who is clinically postmenopausal but with FSH, LH and estradiol that are not in the postmenopausal range?
In this situation, with a low risk, node-negative disease with ambivalent menopausal status, Tamoxifen, unless contraindicated, would be my choice. A SERM is equally effective for premenopausal and postmenopausal women. In the course of adjuvant endocrine therapy, changing to an aromatase inhibitor ...
How do you approach treatment in premenopausal patients who develop a contralateral HR+ breast cancer while already on tamoxifen and ovarian function suppression?
Several pieces of information are lacking in this clinical case to make a solid treatment recommendation: what is the current age of the patient? What is her menopausal status? Is the new contralateral breast cancer clinically node negative? Since this new second primary contralateral breast cancer ...
What adjuvant therapy would you offer an elderly but healthy patient with T2N1 HR+ HER2+ breast cancer who is not willing to receive cytotoxic chemotherapy?
The Japanese RESPECT trial (Sawaki et al., PMID 32936713) compared trastuzumab alone (T) vs chemo+trastuzumab (Ch+T) in patients >=70 and demonstrated a 3 year DFS of 89.5% (T) vs 93.8% (Ch+T) HR 1.31 p=.51. Based on this data, you could discuss adjuvant AI+trastuzumab for 1 year.
How would you treat a post-menopausal woman found to have a node-negative ipsilateral HR+ breast cancer recurrence with pectoral muscle invasion following a prior mastectomy, radiation, and AI therapy completed > 5 years ago?
I would probably give "neoadjuvant" therapy... according to the age of the patients, comorbidities, prior exposure to chemo in the past, and biology of the HR+/HER2-, I would choose between neoadjuvant chemotherapy or neoadjuvant endocrine therapy (with or without a CDK 4/6 inhibitor).
Does the magnitude of OncoType recurrence score above 26 inform decision between TC and AC/T in ER+ HER2- 1-3 node positive, postmenopausal patients with breast cancer?
We don't have any evidence for correlating recurrence score with choice of chemotherapy. Based on RxPONDER, we know that patients with 1-3 positive lymph nodes and scores less than 25, do not benefit from chemotherapy. Based on retrospective data, we have enough evidence that scores more than 30 wou...
Would you offer adjuvant abemaciclib to young, premenopausal women desiring more children who meet criteria for the same based on monarchE trial?
Based on the package insert for abemaciclib, there is no reported risk of early menopause or amenorrhea. CDK4/6 inhibitors are cytostatic (by blocking the transition from G1 to S phase) and not cytotoxic, unlike alkylating chemotherapy. So, I would feel comfortable offering abemaciclib and subsequen...
Would you consider adding neoadjuvant endocrine therapy in a patient with HR+, HER2- breast cancer who has not clinically responded to neoadjuvant chemotherapy?
Generally no, unless conversion to lumpectomy is a goal. If the patient is not a lumpectomy candidate, then I would move on with surgery. Pathological complete responses are low (10%) in ER+ive cancers, thus it is not unusual to see a modest clinical response with chemotherapy.