Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach discussion of adjuvant chemotherapy for a T1b (0.5 cm) hormone positive breast cancer with high risk features and an Oncotype Score of 31?
The best available data suggests that the relative benefit of chemotherapy predicted by gene profiling scores is seen across anatomic stages, but the absolute differences in smaller size node negative tumors will of course be smaller, even with a higher Oncotype Dx score. While precise estimates are...
How would you approach a post-menopausal women with recurrent ER/PR+, HER2- breast cancer only in the axillary lymph nodes?
This sounds so characteristic of a low-grade ER+ tumor in an elderly lady. I would only resect and confirm at resection the above-suspected pathology. Clearly given her age indolent behavior, local recurrence and low volume I would not torture this elderly lady with nothing more than an AI. The prob...
How would you approach a postmenopausal woman with Stage I HR+,HER2- breast cancer who had a CVA while on tamoxifen?
A major co-morbidity such as a stroke should prompt a re evaluation of the benefit risk ratio and overall value of adjuvant endocrine therapy, especially for low risk disease. It would be helpful to unpack this situation a little more. How bad is the stroke and how much loss of mobility and performa...
How would you counsel a patient with HR+, HER2- breast cancer with an OncotypeDx ROR score of 0 who is refusing endocrine therapy?
This is often a challenging case to discuss with patients. Although we know that this patient's likelihood of distant recurrence is very low if she takes 5 years of adjuvant endocrine therapy, we don't actually know what her risk of recurrence is with no systemic therapy. Presumably, those with very...
Would you treat a postmenopausal women with high grade T2N0 ER-, PR+, HER2- invasive ductal carcinoma with upfront surgery or neoadjuvant chemotherapy?
I'd conduct a conversation about NAC, but it isn't clear to me that NAC would change anything for this patient. PR 45% does not qualify as "functionally triple negative" in my book, so I'd consider this still HR+. I would not offer more than AC-T whether NAC or adjuvant. Additionally, I wouldn't off...
How would you approach diagnosis of residual ovarian tissue in a patient with ER positive breast cancer, history of BSO, and a rising estradiol level on tamoxifen?
Diagnosing elevated estrogen levels in a patient who has undergone BSO is difficult, since the symptoms are typically very non-specific (e.g., improvement in hot flashes, change in mood). There are multiple potential reasons for elevated estrogen levels following BSO, including an adrenal tumor that...
Would you use OncoType in a postmenopausal female with HR+/HER2- with LN involvement who clinically meets RxPONDER criteria of 1-3 LN to guide the use of neoadjuvant chemotherapy?
Yes. If I am asked to consider neoadjuvant therapy in a postmenopausal woman with an ER/PR+, HER2 negative cancer, who is otherwise a candidate for chemotherapy, I will start the endocrine therapy and send OncotypeDX to make sure that we are not leaving out an important part of her management, i.e. ...
In which situations do you offer neoadjuvant chemotherapy for a nodal recurrence alone of ER/PR positive, HER2 negative breast cancer?
There is limited evidence to match this scenario on which to base the decision-making. On the one hand, this is a young woman who now has nodal disease. IF she had presented with this as her original diagnosis, the recommendation would have been for adjuvant chemotherapy followed by endocrine therap...
Does the degree of hormone receptor positivity influence your decision to perform Oncotype testing?
In my clinical practice, the degree of hormone receptor (HR) positivity and the clinical characteristics play an important role in ordering the Oncotype testing for HER2-negative tumors. But for 10 to 100%, if the patient is a candidate for chemo or the patient is willing to use this test as part of...
Would you consider OFS in a young patient (<35) with ER+ breast cancer who required chemotherapy and menses resumed years later while on tamoxifen?
The SOFT/TEXT trial demonstrated a DFS/OS benefit for OFS when added to endocrine therapy. Patients at higher risk (<35 years old, node +, treated with chemotherapy) would likely benefit more. The decision to do this depends on her baseline risk. The HER2 status is interesting in that HER2- patients...