Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant treatment approach would you choose for a premenopausal woman with lymph node positive poorly differentiated metaplastic breast cancer that is ER low+, PR+, HER2 negative?
Given the tumor is ER low+ (and I'm going to assume not strongly PR+ in this case since that would be highly unusual in the setting of ER low positivity only...but please comment back if I'm wrong!), yes, I would consider this biologically triple-negative disease (and very high risk given metaplasti...
In a patient with ER+/HER2+ breast cancer with significant residual disease post neoadjuvant TCHP, is there a role of using CDK4/6i in the adjuvant setting with T-DM1?
This is an open question. As has been true in oncology for some time, most of the adjuvant therapies we offer have shown benefit first in the metastatic setting, and then are tested in the adjuvant setting. Abemaciclib has been shown to have benefit when combined with herceptin and endocrine therapy...
How do you approach ovarian function suppression in premenopausal women with HR+/HER2-, node negative breast cancer and intermediate OncoType dx scores (11-25) who received chemotherapy?
The SOFT/TEXT data showed that the patients who benefited from ovarian suppression + endocrine therapy were those who were <35 years old or those who had prior chemotherapy (essentially those patients who were deemed to have high risk disease). The TAILORx study demonstrated that patients with recur...
Do you hold endocrine therapy during adjuvant breast radiotherapy?
I start endocrine therapy after RT. For one, I don’t think there is a rush to get endocrine therapy going and would rather focus on the patient being able to tolerate it for the long term. And two, if radiation works best on quickly dividing cells, I don’t want to stunt their proliferation (which we...
Can you use Oncotype for determining adjuvant therapy in a young, premenopausal woman with multifocal HR+ breast cancer s/p mastectomy with 2 positive lymph nodes?
There are no data yet that I am aware of (retrospective or prospective) for the use of Oncotype 21 gene assay to make treatment decisions in premenopausal women with node positive, estrogen receptor positive early stage breast cancer. The prospective RxPONDER trial will hopefully provide data on the...
In a patient with resected ER+ HER2- breast cancer, how do you decide between TC vs ddAC-T for adjuvant chemotherapy?
I seldom (if ever) use the docetaxel/cyclophosphamide regimen. I find it more toxic than DD-AC-T, so I tend to use the latter once I determine that chemotherapy is indicated. Perhaps a more fundamental question for these patients is which needs or is likely to benefit from chemotherapy. If I have an...
Do you use platinum therapy in BRCA1 mutated patients with ER/PR positive disease receiving neoadjuvant chemotherapy?
In the absence of any data (of which I am aware) of benefit from adding a platinum analog to neoadjuvant chemotherapy in BRCA1-mutated patients with ER-positive/HER2-negative cancers (other than those with minimal ER expression, whom I treat as I do patients with triple-negative cancers, with the ad...
How do you approach recurrent, localized HR+, HER2- breast cancer in a patient who has progressed on exemestane (and previously on letrozole and tamoxifen)?
If the tumor is not resectable, I would use fulvestrant and a CDK inhibitor; but if the ER/PR expression is low, I might consider pre-operative chemotherapy using a standard adjuvant chemotherapy regimen—most likely AC-T. If the tumor is resectable (or has been resected), then I would use adjuvant c...
How do you approach recommending tamoxifen in a premenopausal woman with Li Fraumeni syndrome and early stage low risk ER+ breast cancer?
The risk of uterine sarcoma is 17 per 100,000 patients per year on tamoxifen which is higher than the average population, i.e., 2 per 100,000 patients per year. The lifetime risk of soft tissue sarcoma in Li Fraumeni Syndrome (LFS) female patients is about 15%. In a series of 64 LFS breast cancer pa...
Are pre-menopausal women on tamoxifen at risk for endometrial cancer?
Analysis of endometrial cancer rates in the NSABP P1 trial in women under age 50, demonstrated a relative risk of 1.42 (0.55-3.81) for tamoxifen that was not statistically significant. Per 1000 women, the rates were 0.82 for placebo and 1.16 for tamoxifen. (Fisher et al., PMID 16288118)