Breast Cancer
Questions discussed in this category
Are there any subgroups that would still benefit from RNI?
Would it matter if the patient did or did not have a pathologic CR in the breast?
Would you offer adjuvant Pembrolizumab combined with Capecitabine?
This boost would be in addition to the standard regional nodal irradiation delivered post-op.
Does the low ER+ or metaplastic histology affect your recommendations?
Isn't there a tradeoff of increased lung dose?
Disease is not responding to systemic therapy.
Would you expect a difference in skin reaction?
When treating nodes in the post mastectomy setting, what dose/coverage do you find acceptable to the nodal regions versus to the chest wall/reconstruc...
Are you routinely offering a 16-fraction course of hypofractionated PMRT for patients undergoing breast reconstruction versus a traditional 25-fractio...
Patient with pT2 N2a (6/9 LN+, 5 with macromets, 1 with focal ENE) ER/PR+, Her2- s/p mastectomy.
Is there compelling reason to start PMRT prior...
If no enlarged lymph nodes on imaging, and no other high risk features. Would your opinion change if the patient has had prior breast radiation?
Given the very low lymphedema rates associated with these procedures, does it impact your choice for axillary management?
Should the answer differ for cN1 luminal disease vs. cN0 TNBC?
What would be your approach to a patient who went straight to surgery due to HR+ biopsy, but found to be triple negative on surgical pathology?
How should ECE influence radiotherapy in breast cancer?
For T1-2 patients with N1 disease after sentinel node biopsy alone and upfront mastectomy (gr...
Would you treat with curative intent (neoadjuvant chemotherapy, surgery, and radiation to include the sternum)?
Would you cover the chest wall alone or would it be chest wall plus regional nodes?
Patient factors: no prior radiation therapy
PFS curves appear similar between the AKT-altered vs overall study population in the trial publication. Is there any additional information available ...
For instance, would you incorporate use of Oncotype DX in this patient population to guide decision making on the use of regional nodal irradiation?
The patient is an elderly female with a good KPS who presented with a cT2N1 triple-negative breast cancer.
The patient refused chemotherapy and immun...
Such as breast plans with < 200 cGy mean heart dose
For example, when would you recommend clinical exam for surveillance versus imaging with MRI, CT or PET?
Would you feel confident in omission for residual disease in the breast and only 1 LN removed during SLNB, which is the same node that was biopsied up...
Would you be more inclined to use it if a patient had early discontinuation of pembrolizumab due to IRAE?
Patient underwent an axillary dissection with ITCs in 1/23 nodes.
Oncotype score in this case was 14.
Add OFS with endocrine therapy plus Taxane-HP combo? What taxane is preferred?
The SOUND trial looked at sentinel node versus observation in patients of any age with breast cancer up to 2 cm and a negative preoperative axillary u...
Although grade 3 toxicity rates were low, ~10.5% experience some degree of ILD, are there strategies to reduce risk before treatment starts?
Are ther...
Would prior RT (>30 years ago in this case) to the breast or ATM mutation alter your recommendations?
How would you counsel the patient given the drug interactions present?
For example, women of southeast Asian descent.
Any pitfalls to be aware of?
Would clinical stage or nodal status affect your decision?
How would you approach treatment with systemic therapy, surgery, and radiation if there is evidence of little treatment response, tumor growth, and ne...
In what circumstances would you offer or avoid APBI in a woman with an oncoplastic closure after lumpectomy?
As immune checkpoint inhibitors have expanded into the neoadjuvant breast cancer setting, severe and unexpected autoimmune toxicities may cause delays...
In my experience, high tangents are commonly used for patients with pN1mic disease, and occasionally for higher risk patients with pN0 disease. The re...
What factors would influence your decision?
Given the results of DESTINY-Breast03, and T-DXd's labeled indication in second-line, what is now the role of TDM1 in the treatment armamentarium of H...
Which regimen is preferred in second line for these patients? What is the efficacy of TDXd vs tucatinib in CNS metastases?
Since HR low-positive, HER2 neg tumors behave aggressively similar to TNBC, does the degree of HR positivity factor into your decision-making?
How do you use 105%, 107% and max dose metrics differently compared with non-reconstructed cases?
Does the type of breast cancer factor into your decision making?
Can adjuvant radiation therapy compensate for the potential increased local recurrence risk?
Would you no longer trust the prognostic value of Mammaprint knowing the poor response to endocrine therapy?
What would you consider when thinking about your boost?
Due to multiple complicating factors including travel distance of ~1 hour each way, this patient (mid-60s) refuses to come any more often than 2 days ...
What is your treatment algorithm?
If a patient is found to have 2 lymph nodes positive with ECE s/p mastectomy, axillary dissection, tissue reconstruction, and lympho-venous bypa...
Any concern for increased risk of radiation recall?
Would you consider administering Keytruda (pembrolizumab) concurrently with radiation therapy for the treatment of a patient with an ER-negative, PR-n...
As expected triple negative.
Z0011 population, cN0 with 1-2 SLN involvement with a low likelihood for additional non SLN metastases?
Is there data on the long-term effects of abemaciclib on future fertility and pregnancy after its discontinuation?
Does the patient's desire for futu...
The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial suggestin...
For standard tangential radiation would you pull the field edge forward to avoid radiation dose to the entire implant?
Would your recommendation change if the patient had a high Oncotype and received adjuvant chemotherapy?
What are the current criteria in 2023 for selection to complete sentinel node biopsy or skipping of sentinel node biopsy specific to age, grade, clini...
If a patient had a stage I contralateral breast cancer and received bilateral mastectomies with implant reconstruction 2 decades ago and now has ...
Is there a role for loco-regional treatment in this scenario? If a young patient with ER/PR positive cT2N2M1 IDC presents with a single bone metastasi...
What dose constraints do you use for the left anterior descending artery (LAD) for breast radiation?
Is there data to support those constraints?
In the setting of the recent TailorRx data, would these patients be considered more high risk?
Would you still treat with neoadjuvant KEYNOTE-522?
For a patient with high risk disease and a severe enough reaction that additional taxane-based therapy is contraindicated, do you consider alternate c...
If so, what dose-fractionation do you utilize? What other factors do you take into consideration?
For additional reading, see JCO OGR (11/2021) by Drs. @Warren and @Bellon reviewing the landscape of adjuvant treatment after lumpectomy for DCIS and ...
Would you recommend aiming for the postmenopausal range as per the lab reference range or do you have a specific goal?
Would you do a tumor bed boost in the absence of other risk factors?
Do young, early-stage breast cancer patients with pCR to chemoimmunotherapy still benefit from PMRT?
If a patient in her 30s with a cT2N0 triple negative breast cancer has a pathologic complete response (pCR) after chemo/immunotherapy at the time of m...
Does the presence of other cardiac risk factors change your recommendation?
Would you ever consider any of the following?
Discontinue the bolus after brisk reaction
Moderate hypofractionation to the chest wall instead of c...
Initial path was T1cN0, and recurrence shows 2/21 ALN involved with ENE, what would you recommend for therapy?
Would you give neoadjuvant chemo or hormonal therapy or go with surgery first? What chemotherapy would you use?
Patient with stage IV ER+PR+Her2- breast cancer progressed after CDK4/6 inhibitor+AI and then on Elacestrant. Guardant 360 showed ESR1 mutation and PI...
Controlled extracranial disease on trastuzumab+pertuzumab for 2 years. Treatment options include Enhertu or WBRT. Not a candidate for SRS or neurosurg...
The patient had a high-grade DCIS with necrosis, but a 0.9 DCSionRT score
In MONALEESA-2, it appears ~22% of those in the ribcociclib group received a subsequent CDK4/6 inhibitor. What was the rationale and could this have i...
Are there other systemic therapy considerations to help achieve sufficient CNS control?
Given OlympiA trial with olaparib benefit for gBRCA+ patients?What are barriers that you foresee? In your practice who performs mutation testing and w...
The patient is an otherwise healthy patient in her 60s with an ER-positive, PR-positive, HER2 negative grade 3 pT1N0 invasive ductal carcinoma followi...
Would you offer adjuvant radiation therapy if pCR is confirmed?
If so, what dose would you utilize for the SIB? When utilizing a boost with ultra-hypofractionated whole breast RT, would you favor adding a single fr...
The patient had ER/PR positive, early-stage recurrent disease superficial to the prior RT site involving the nipple and dermis without ulceration, tot...
Would you recommend this for a focally +, diffusely +, grossly + margin? What would you expect local recurrence rate for diffusely (+) microscopic mar...
Group 3 being ratio < 2, copy # >6, and IHC 2+
My understanding is that if someone isn’t medically operable, the default is to offer systemic therapy palliatively because breast cancer is tho...
This patient had a T1N0, ER/PR negative, HER2 negative breast cancer
If a patient had a CPS-EG of 2 after neoadjuvant therapy, would you offer that patient olaparib even though she wouldn't have met entry criteria? If t...
Role of capivasertib vs SERD? What factors help you decide?
In a young patient <30 years old with large pre-chemotherapy, multifocal disease with pCR following mastectomy, would you consider extrapolating th...
How does it affect your calculation of risk stratification?
Do you give first-line CDK 4/6 inhibitors with Tamoxifen or Aromatase Inhibitor (+/- GnRH analog)?
Would you consider pentoxifylline and vitamin E to mitigate fibrosis?
Good risk DCIS as per RTOG 9804
Should these patients have a different threshold for utilizing a CDK4/6 inhibitor in the front line metastatic or as part of adjuvant therapy, or SERD...
The patient had a prior right-sided ER+ HER2-ve breast cancer, treated with neoadjuvant chemotherapy, MRM with ALND, and PMRT
They recently developed...
How do you stage and evaluate premenopausal patients with >= cN1 ER+ PR+ HER2- breast cancer prior to surgery to avoid this pitfall?
Do you feel differently about using these in patients with a history of HR-negative breast cancer?
Are there any skin care products you would avoid in this population?
In a patient who had a wide local excision and radiotherapy 10 years ago and now recurs with cT4 disease, would you repeat radiation after neoadjuvant...
How does age, grade, hormone receptors play into your decision?
Would postmastectomy radiotherapy ever be indicated in a young patient with close margins and a massive (14 cm) DCIS breast tumor interspersed with le...
Assume each lesion would have been suitable for partial breast radiation
In an asymptomatic patient, would this be safe?Is there any reason to withhold radiation such as in the case of T1N0 breast cancer advising the patien...
For example, if a patient is otherwise a candidate for APBI with a 1.5 cm primary tumor but has 2 cm of associated DCIS would the patient be ineligibl...
Would you start with endocrine therapy + CDK 4/6 inhibitor or a chemotherapy based regimen?
If so, in what situations?
RIGHT Choice trial presented at SABCS 2022
Would you still treat the chest wall with standard dose and give the patient the benefit of the doubt in the absence of pathological confirmation of m...
NRG-BR002 (Chmura et al., JCO 2022)
CURB (Tsai et al., IJROBP 2022)
Young healthy patient, ER/PR positive HER2 negative right breast cancer with a synchronous single site of oligometastatic disease in the right 4th rib...
Do your post-operative treatment recommendations differ for benign vs. malignant phyllodes tumors of the breast?
Is phyllodes tumor size ever a crite...
How does this change for patients with elevated bilirubin?
For example, if preoperative imaging indicates T3 disease (non-mass enhancement extending over 5cm) but final pathology s/p mastectomy shows multiple ...
I trained at a place where use of a bolus for chest wall irradiation PMRT was standard practice, but this is not so at my practice right now. Assuming...
Do you use SIB regimen (40/48 Gy) per RTOG 1005 for whole breast radiation in scenarios not included on trial? For example: a patient who has received...
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
How does data from PADA-1 and EMERALD trials impact your decision-making?
Her gynecologist wants her on hormone replacement therapy.
For example, a patient has had multiple dose reductions for neutropenia and required an admission for infection while on palbociclib. Would you switch...
In prior ASTRO guidelines, it was mentioned as a cautionary group for IDC but not in the 2023 updated guidelines.
Based on Mill et al. paper showing increased IBTR rates with ILC vs IDC (Mills et al., PMID 34516030)
The patient previously received endocrine therapy alone and in combination with CDK 4/6 inhibitor. She does not have any targetable mutations on NGS. ...
If a patient has a genetic mutation, but not necessarily the classic ones where we avoid radiation (ATM, BRCA, p53, etc.), does this change your treat...
Do you take PR percent into account?
What data may support the routine escalation of endocrine therapy? Should HER2 therapy be prioritized instead?
Would you treat with 1st line ET + CDK4/6 inhibitor if the patient is only low or moderately ER positive?
Would you consider OFS this far out from diagnosis and treatment in a young patient with high grade IDC was treated during pregnancy with neoadjuvant ...
The patient is in her 40s with a BRCA-2 mutation and underwent bilateral prophylactic nipple-sparing, skin-sparing mastectomy. No sentinel nodes were ...
Additionally, when evaluating margin status for APBI IMRT 30 Gy in 5 fractions which specifies at least 5 mm margins, do you look at the DCIS margin o...
Patients are understandably concerned about the risks and benefits of radiation to an oozing, bleeding, and ulcerated breast.
ABS APBI guidelines are much more permissive relative to the newer ASTRO Guidelines.
Would you change your recommendations for APBI vs whole-breast RT for this reason?
NSABP B-51 recommends V3<10% or a variation acceptable of V5<10% for contralateral breast. Is there a limit needed for contralateral chest wall/...
Do you advocate for completion ALND? If so, would you radiate the dissected axilla?
Would you especially consider RT omission in the setting of low-grade, small-volume disease with no underlying DCIS or invasive disease component on p...
How do you reconcile the apparent benefit in all patients in this group as opposed to the differential effects in premenopausal HR+ node-negative pati...
Are you more worried about QT prolongation in this subset of patients?
How would you approach a young woman (under the age of 50) with DCIS with favorable disease (ER+, low grade, small size <5mm, negative margins)?
What type of adjuvant chemotherapy would you offer? Would clinically positive lymph nodes or residual disease at the time of surgery change your decis...
Do you recommend observation, APBI, whole breast or whole breast with low axilla treatment?
Would you consider doing this in patients with adverse features such as grade 3 or PR negative status?
Did your treatment inclinations change with the results of the recent FABREC trial (NCT03422003) presented at ASTRO?
Would you consider eliminating radiation to the chest wall in a patient greater than 50 years of age with a T3N0M0 grade 2, ER+/PR+ Her2 negative inva...
I.e., the IDC was completely removed during biopsy, but DCIS was present on post-lumpectomy specimen with close anterior margin
A female in her 60's was simultaneously diagnosed with stage I triple-negative left breast cancer and stage I NSCLC of the left lung.
The patient had...
In which particular patient cases or clinical scenarios would you consider preferentially treating a patient with protons over photons?
Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?
Nodal staging changes radiation fields, but given increasing pertinent null findings of a positive SLNBx with regards to outcomes, I wonder if ypN0 is...
What total heart dose and LAD dose do you typically utilize to justify the DIBH technique?
If a patient was noted to have poorly differentiated histology with two tumor foci in the breast, positive LVSI, and isolated tumor cells in 1/3 senti...
The patient is a female in her 50s with luminal B pT1b pN1(sn) invasive ductal carcinoma with 2/2 nodes, 5 mm ECE, and extensive LVI. No preoperative ...
For example, would you consider treating part of the humeral head if required to adequately cover the axillary nodal volume CTV/PTV?
Would you biopsy a metastatic site?
Would you consider APBI for an ER/PR/HER2 negative pT1-2 N0 with pathologic complete response after neoadjuvant chemotherapy? Would the presence...
In what scenarios do the benefits of local control with PMRT outweigh the risks?
How would systemic therapy and/or the number of bone metastases impa...
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
A patient presents with clinically node-positive cT2 grade 3 invasive breast cancer in the upper outer quadrant. The patient had breast RT to 50 Gy wi...
What constraints would you use for ribs, lungs, and heart?
MONARCHE added an amendment to their protocol to exclude inflammatory breast cancer so they technically would not qualify for the trial though it's ha...
If yes, how do you assess the tumor response and how frequently while on neoadjuvant chemoimmunotherapy?
Patient is pre-menopausal and has cT3cN1, grade 2, ER positive, Her 2 negative IDC. Metastatic disease to axillary LNs was biopsy-proven. Patient was ...
Would you consider offering ovarian suppression?
The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...
Is deferring chemotherapy based on low oncotype acceptable in setting of recurrence?
Would you recommend using a different AI, Tam...
If a patient has a small luminal A invasive tumor resected to negative margins with admixed high-grade DCIS, does the high-grade DCIS component influe...
Would you recommend using chemotherapy based on RxPonder regardless of Oncotype score in a premenopausal patient? Or would you hold chemotherapy since...
What prophylactic strategies you use to mitigate the risk?
What dose and fractionation do you use?
If a patient is <50 years old, would this change your recommendation?
The patient is an otherwise healthy female in her 70s with an ER-positive, PR-negative, HER2-negative grade 3 invasive ductal carcinoma.
Lumpectomy r...
The patient was treated with neoadjuvant chemotherapy and had mastectomy with SLNBx about 6 months prior to being referred for adjuvant radiation.
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
If the dose to these OARs deviates from goal by a significant margin, how do you approach changing the treatment plan, accordingly?
Is there absolute LVEF threshold you would not use HER2 targeted therapies?
Would you consider using endocrine therapy, pembrolizumab, capecitabine, or CDK 4/6 inhibitor?
For a node positive, triple negative patient that underwent neoadjuvant chemotherapy followed by breast conservation with a complete pathologic respon...
What criteria do you use to determine the utility of using DIBH for planning after free breathing and DIBH CT scans?
Do you typically create a ...
The IMPORT-LOW and DBCG trials of 40 Gy in 15 fraction PBI utilized mini-tangents, which simplify planning but increase breast V40 Gy.The paper by Tho...
The GEPAR trials presented at ASCO 2015 showed increased LRR with the omission of RT in patients who had a pCR after neoadjuvant chemotherapy.
For a patient with an ER-positive, pT1c breast cancer who otherwise meets criteria for APBI, but has a BMI of 50 with pendulous breasts and N1mi disea...
While I am encouraged by the results of the LUMINA trial with respect to identifying patients who are less likely to benefit from radiation therapy wh...
The patient is on a dose of 22 mg of methotrexate weekly for severe rheumatoid arthritis.
If you would discontinue the methotrexate, how long would y...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
Might a prior SJ incident pre-dispose to SJ reaction to radiation?
Would you be more or less apt to treat with RT for grade 2 DCIS with refusal of pr...
If a patient had a partial mastectomy and radiation therapy 10 years ago and now has a large ipslateral breast cancer (different ER/PR/Her 2 markers n...
NCCN suggests 2 - 4mm margins in DCIS, and no tumor on ink with invasive disease.
What agents have you found helpful? What agents have been proven to be effective/non-effective?
The patient is less than 35 years old, and received 21 Gy to the mantle and 10.5 Gy to the lungs >15 years ago as part of treatment for Hodgkins ly...
Did the EBCTCG meta-analysis change your practice?
Had mastectomy resulting in ypT1cN1a. Post menopausal female with good PS.
For patients who are otherwise eligible for CALGB 9343 and candidates for APBI who choose to proceed with partial breast RT, are you offering 26 Gy in...
If so, under what circumstances?
The patient is a woman in her 30s with a grade 2 T3N0 ER/PR+ Her2- invasive ductal carcinoma who was treated with mastectomy (margin negative, but LVI...
If NGS was positive would you treat with HER2 directed therapy? How, if at all, would you incorporate T-DXd into this treatment paradigm?
She achieved PCR with NAC with TCHP and is now on adjuvant HP.
Do biomarkers impact your decision-making? If you were to boost, what dose would you use?
Do you use CBCT or kV images? Do you match to the breast or the chest wall?
The patient had 0/2 sentinel lymph nodes involved, and mastectomy revealed pT3 disease with negative margins
Is there a practical way to quanitfy risk of LRR in patients with T1-2 N0 with multiple high risk factors in such as multifocal disease, high grade, L...
Would you recommend this if we were treating level I/II?
The patient has locally advanced disease with chest wall invasion and extensive axillary/IMN lymphadenopathy
In which scenarios would you consider a parp inhibitor as the first line treatment of choice?
Is axillary radiotherapy an acceptable alternative?
Tumor 3 cm, grade 2 with Ki-67 25%
Please specify how your institution is allocating resources now or will be soon.
How do you reconcile these findings with the ABC trials?
Are there any concerns about increased acute or late toxicity in the context of more extensive surgery?
(Assuming they meet MonarchE criteria)
For example, if the patient is in year 2, 3, 4, or 5 of adjuvant endocrine therapy versus 9 months out, would ...
Is there a role for KEYNOTE-522 since ER + metaplastic breast cancer have similar behavior to triple negative metaplastic breast cancer?
What is your approach to try to persuade her that photons would be a better option?
Historically, chemotherapy has been delivered prior to radiation for breast cancer patients requiring it.
With the acceptance of shorter cour...
If yes, where in sequence would you use it?
Received neoadjuvant ddAC/T followed by adjuvant capecitabine for residual disease and found to have metastatic pulmonary nodules within months of sur...
Does your approach differ across the HER2 IHC spectrum?
Do you use a q4 week or q12 week formulation? If you use both in your practice, what factors into your decision making for either one?
I have yet to see results from the SUPREMO trial investigating this question in Europe.
There is the EXPERT trial, NCT02889874 based in Australia/New...
What do you consider valid reasons to deliver 39 or more fractions for prostate cancers, 25 or more fractions for breast cancers or 10 or more fractio...
Would you consider APBI so that less tissue is irradiated or do whole breast (hypofractionation vs conventional fractionation)?
The patient is in her 70s and had a prior breast recurrence 10 years ago treated with mastectomy and reconstruction; this most recent recurrence has t...
How strongly would you recommend it for a grade 1, < 1 cm DCIS?
The surgeons at our institution are asking for repeat markers but I am not aware of any data or guidelines to support this.
Patient with multiple comorbidities (childhood CNS cancer survivor, stroke with residual deficits).
The patient did not have radiation previously, but now has recurrent disease in Axillary levels 1-3, supraclavicular nodes, and IMN in the first inter...
MonarchE trial criteria includes "patients with four or more positive nodes, or one to three nodes and either tumor size ≥ 5 cm, histologic grade 3...
Assuming aromatase inhibitor is not an option due to severe osteoporosis or if it is a man with breast cancer.
The ASTRO consensus lists 2-3cm size as cautionary, while the ABS consensus lists 3cm or less as suitable, though acknowledges that most patients incl...
Is there any reason that this is not commonly done, apart from lack of RNI coverage?
Is there any role for AI + OS? What duration of therapy do you recommend?
The patient had lumpectomy with standard radiotherapy to 50 Gy whole breast, followed by 10 Gy boost 11 years ago, and was recently found to have a sm...
Fertility preservation already complete with embryo cryopreservation
Patient is refusing BID dosing as per RTOG 1014.
Patient developed pembrolizumab-related pneumonitis after ddAC followed by Taxol/Keytruda - what thresholds/constraints would you prioritize with rega...
Do you also use DIBH in these cases?
Or would it change your decision on a boost in WBRT if negative surgical margins?
Why do the available guidelines restrict APBI to patients with lesion size <3cm? Is this purely from higher rates of necrosis noted in older brachy...
If so, are there any patient/pathology selection factors? What technique do you utilize?
She had been initially treated with neoadjuvant AC-T followed by BCS and RT with high burden residual disease in the breast and lymph nodes.
Are there any resources comparing whichever value is more relevant for the various breast fractionation schedules (FAST, FAST-Forward, Canadian, UK, 3...
If a patient is found to have florid LCIS with with a 1 cm positive inferior margin s/p sentinel node biopsy (0/2 nodes involved) and mastectomy, is t...
For example, a heavy burden of nodal disease with diffuse ECE? Would you treat the axilla higher than 45-50 Gy? What would you use for a boost dose?
Do you follow the breast NCCN guidelines to decide adjuvant radiation recommendations if a patient treated with neoadjuvant chemotherapy stops the che...
The results presented by Sudeep Gupta (from the Tata Memorial Breast Group at 2022 San Antonio Breast Cancer Symposium #GS5-01) showed no benefit (pCR...
Is there a certain amount of time that you prefer to have elapsed after the last infusion before delivering SRS? Do you avoid all subsequent Trastuzum...
Patients will frequently ask why they need treatment when there is no cancer left on the pathology specimen.
The patient is now s/p neoadjuvant chemotherapy, mastectomy, and ALND for their ipsilateral recurrence, and pathology showing residual disease (ypT0N2...
If so, which patient population would you use this in?
Markers from surgical path showed ER0PR0 HER2 2+ and positive via FISH in 5% of total tumor population.
If so, would you also include the breast?
Would you offer APBI if the DCIS was ER-?
If a patient with early-stage breast cancer s/p lumpectomy is noted to have 1/3 SLNs positive for ITCs (and no other negative prognostic factors) woul...
The patient is a woman in her 60s with a history of a grade 1 ER-positive, HER2 negative pT1bN0 invasive ductal carcinoma treated with lumpectomy, who...
Would you radiate concurrently with WBRT? How would you dose/fractionate in this situation?
What if positive margin is felt to be from a DCIS skip lesion (initial DCIS margins widely negative but small focus DCIS found in additional tissue wi...
Do you have recommendations on timing of her implant placement with respect to radiation therapy?
Masuda et al. NEJM 2017
If so, how do you sequence it with adjuvant radiotherapy?
Since both pregnancy and cancer are risk factors for VTE, is there data to guide when or if we should prophylactically anticoagulate? If so, what shou...
Are there specific patient populations in which you may feel comfortable with a patient selecting only one adjuvant therapy approach (tamoxifen vs RT)...
The patient was a >70-year-old with right-sided cT3N1M0, ypT0N0 TNBC s/p NAC pembro/taxol x 4 cycles followed by mastectomy w SLN (0/4); post-opera...
Is a FAST regimen reasonable in this circumstance, or should a more gentle fractionation (either the RTOG re-treatment regimen, IMPORT-LOW, or 45Gy in...
For a > 70-year-old female patient with 2 mm of ER+ PR+ HER2- grade 1 invasive ductal carcinoma in background of 1 cm of grade 3 DCIS, would you re...
Is there a subset of patients for which you consider one regimen over the other (i.e. AC-THP v.TCHP)? If using an anthracycline regimen, do you u...
Would you boost a resected axilla if extra-nodal extension is found in a patient with breast cancer?
What are your volumes? What if the lymph node area was not clipped?
With studies showing non inferiority to zoledronic acid q 3 months in support of bone metastatic disease, would you consider extrapolating this data a...
The patient is BRCA2 positive and previously received 30 Gy in 5 fraction APBI to the right breast for an ER/PR+ pT2N0 IDC. She then developed multifo...
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
Assume a mild but diffuse case of lichens sclerosis with involvement of the ipsilateral breast. If node negative disease, would you recommend she unde...
Does that change if they received a skin sparing mastectomy?
For a cT2 triple negative breast cancer with indeterminate enlarged breast nodes s/p negative biopsies, and indeterminate findings on both MRI and PET...
If a patient with endometrial stromal sarcoma managed with fulverstrant has a single oligoprogressive lung nodule, is there any contraindication to tr...
For conventional fractionation, should one increase total dose above 60 Gy for either close or positive margin (invasive or DCIS). What about for acce...
Patient is declining mastectomy.
How do you compare their efficacy overall?
Would you obtain baseline PFT on all patients or only selected high risk patients? Would you repeat PFTs regularly or only if clinically symptomatic?&...
If electrons are unable to be used, or if the patient's anatomy precludes use of electron treatment, what is your general approach to using IMRT in th...
Given strong TDXd efficacy in these patients is there a role to use it earlier than 2nd line?
How does prior Her2-directed and/or taxane therapy...
Would you consider hypofractionation? If so,what dose? Would you consider a boost if there were close margins?
While rare, these patients were excluded from all frontline CDK4/6 inhibitor trials. Is there any data on the efficacy of ribociclib in the CNS or abi...
Would you change to a different CDK4/6 inhibitor or avoid the entire class of drugs?
Results with fulvestrant and letrozole backbone in MONALEESA and MONARCH trials seem comparable, but PALOMA data is somewhat mixed. How do these trial...
Subgroup analyses in MONALEESA-2 suggest more benefit in de novo treatment naive patients, which is in contrast to MONARCH-3 data presented at ESMO 20...
I have heard of long-term pentoxifylline and Vitamin E daily combination that can prevent and even reverse radiation fibrosis (Delanian et al., PMID 1...
How significant does the moist desquamation need to be? Does the length of tretment remaining ( i.e. 1 v. 3 weeks) or use of medication effect your de...
Is a bra that can be worn during treatment and indexed ever advisable for patients with large breasts who are otherwise unable to do prone treatment?
...
How would you modify this based on endopredict or RT-PCR?
What subsequent adjuvant therapy would you recommend?
What advantages/disadvantages are there between assays or over traditional clinical pathologic factors? What other concerns do you have?For additional...
Would you recommend adjuvant chemotherapy for pT4 disease regardless of Oncotype score?
Would you offer it to a woman with a history of a provoked DVT?
If a patient previously received taxane-based chemotherapy for the initial cancer, is additional chemotherapy recommended or can HER2-directed and hor...
What is your rationale for your approach?
Does your treatment in any way depend on stage, extent of RT, and/or dose to OARs?
Is the marginal advantage of AC/T in 1-3 node positive outweighed by toxicity such as risk of cardiotoxicity and leukemia, regardless of RS?
In a patient who had BCS and adjuvant radiation to the breast and regional nodes, now several years later with extensive axillary recurrence s/p axill...
Patient has declined endocrine therapy and is unfit for systemic therapy.
Can you use 50 mg BID if intolerant to 150 mg and 100 mg dosing? Any tips for side effect management to help patients stay on full duration?
The patient was in her 30s with a 2.8 cm benign phyllodes tumor with positive margin at the posterior fascia. Surgical resection is not considered ide...
MonarchE shows statistically significant improvement in IDFS and DRFS, but the magnitude of absolute benefit is modest (3-year IDFS and DRFS rates = 5...
How do you define an “adequate” axillary dissection, (i.e., would 8 lymph nodes dissection instead of 10 be “adequate”), or ch...
Is there any evidence to support the theory that this may cause worse skin reaction?
Some payors prefer leuprolide acetate injectable suspension (eligard) for ovarian suppression. This is not the preparation that was used in SOFT/Text ...
The patient has notable lip lesions from her discoid lupus erythematosus
In patients with small breasts and large lumpectomy cavities, is there a benefit to switching to whole breast if you can produce a very homogenous par...
If a patient has T2N0 disease without LVSI, but has a ~4 mm IMN node in the 4th or 5th intercostal space, would you be inclined to include the IMN cha...
It is not clear from CREATE-X whether radiation was before or after capecitabine. Is there a preferred approach?
Assuming chemotherapy is indicated because of the Oncotype score.
Patient had significant GI side effects with Trental. (This particular case involved a second course of radiation for a secondary lung cancer 30+ year...
Would you give anthracycline based regimen in a patient with stage III TNBC?
Majority of patients on MonarchE received neoadjuvant/adjuvant chemo.
Does the availability of abemaciclib impact your decision to offer chemo ...
If the patient were of young age with high grade and ER+ disease without LVI, do these factors sway you one way or another?
Patient had estradiol level checked by her gynecologist due to recent irregular bleeding. Estradiol level was markedly elevated on initial testing (90...
In a setting of standard fractionation, we would sometimes consider going to 66Gy total dose to the boost cavity, so how would you "translate" this to...
Patient is young. Bilirubin normalizes when tucatinib is held, but again increases to grade 2 when it is restarted. Evaluation for hemolysis was negat...
We have a lot of push from our surgeons to do IORT, do you use the ASTRO APBI criteria? Do you treat off-protocol? Do you use Xoft or Intrabeam?
With newly published long-term data of single fraction IOeRT (Intraoperative electron Radiation Therapy) for breast cancer on the ELIOT trial, does th...
Assume no contraindications to hypofractionation.
Do you look into their stage/risk to decide? Since patients can experience bone loss after stopping denosumab, how do you plan to discontinue?
How reliable is somatic testing to detect an underlying germline predisposition?
What if the duration of neoadjuvant therapy has been less than 6 months?
What steps should be taken when switching premenopausal women from tamoxifen to AI? In this case, the change is due to newly discovered endometrial th...
For example, if the primary breast tumor was HER2 IHC 1+, but a metastatic site was HER2 IHC 0, would you still recommend using T-DXd?
Will you chang...
If negative margins can be obtained, would you consider breast conversation therapy? If so, would you recommend bolus placement over lumpectomy scar?I...
Is there evidence that T-DXd crosses the blood-brain barrier?
Prior studies have shown that there can be significant variation between grading pathologists as to which samples are defined as HER2 IHC +1 versus HE...
Patient is a post-menopausal woman with 4 lymph node mets that was strongly ER+/PR+, HER2-negative invasive ductal carcinoma with a high Ki-67 w...
Would you use a different endocrine therapy treatment? Would you use indicators other than Oncotype to guide the need for chemotherapy?
If a patient develops a new erythematous macular rash in the exact area of the prior radiation portal months following completion of RT without new me...
The NCCN Breast guidelines specify that for a patient with Paget's disease of the NAC with a positive full-thickness skin biopsy of involved NAC but a...
Specifically, how do you consider T-DXd use in setting of other antibody-drug conjugates (e.g. sacituzumab vedotin)? Are there any special considerati...
Do you prophylactically start all patients on B12, B-complex, and/or omega-3? If so, what dose? What about ice mittens and booties?
If a patient has a painful breast lesion in the setting of rapidly progressing systemic disease treated with weekly taxol (60 mg/m2), would you feel c...
Would ypN1mi after neoadjuvant endocrine therapy cause you to recommend postmastectomy radiation? Or regional nodal coverage after breast conservation...
The patient is a young female with a pT2N1a ER/PR positive, Her-2 positive invasive ductal carcinoma of the upper inner quadrant of the right breast s...
- monarchE included <1% Stage IA and < 5% patients with no chemotherapy.Ex: 64 yo, ER/PR 95%, Ki67 20%, cT1c N0 but pT1c N1a at lumpectomy/SLN b...
For example, are you more likely to incorporate T-DXd earlier in sequence for 2+ vs 1+?
Is there any justification to change our approach in HER2-zer...
Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...
Are you able to achieve the contralateral breast and lung V5 constraints from current protocols?
In patients with prior perioperative immunotherapy with early relapse, would re-introduction of immunotherapy be reasonable with high TMB?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
At initial diagnosis she had T1cN0 disease treated with lumpectomy and SLNB followed by 12 weeks of paclitaxel with 1 year of trastuzumab.
Definitions for "high risk" differ by whether patients receive neoadjuvant chemo and across other contemporary studies. Does the change in AJCC stagin...
Do you perceive a difference between somatic vs germline BRCA mutations?
What if Medical Oncology wants to give more systemic therapy and further delay XRT start date?What should we be telling the Breast/Plastic surgeon/Med...
Would you consider APBI despite younger age?
Do you typically aim to wait a certain amount of time to allow for healing? The range seems to be 4-6 weeks but 4 seems a bit early with potential ser...
The patient had been treated with conventional fractionation to bilateral breasts in the past as treatment for her synchronous IDC.She is currently in...
Would you consider definitive local therapy (surgery, radiation?) if she achieved a good response to initial systemic therapy?
In a patient not receiving adjuvant chemotherapy who has a delayed consultation due to complications/personal issues, etc, is there a time delay ...
Would you include a CDK4/6 inhibitor knowing the patient doesn't meet criteria of monarchE trial but still is Stage IV?
Would you ever consider using these in sequence?
Would you consider omitting treatment if small tumor and early stage? Or would you use tamoxifen?
Patient was initially ER positive, HER2 positive. Currently she is on letrozole. Recurrence is ER/PR negative and HER2 positive and developed almost 2...
What role or experience is there for noninvasive bioimpedance spectroscopy (BIS) devices (SOZO)?
If a patient had prior breast conserving treatment and now has inflammatory breast disease, would you prophylactical send the patient to a cardiologis...
OlympiA trial did not include her2+ breast cancer.
Would you ever offer pre-operative radiotherapy in carefully selected patients before primary oncologic surgery off-trial, based on this Lancet Oncolo...
The OncotypeDx score was 51 in this scenario.
Less than 2cm in size and closest margin is 0.6mm. Would you consider re-excision or mastectomy? Would you offer radiotherapy?
ER low being 1-9% (<10%), PR 20%
Young patient, germline BRCA carrier with cT1cN0 to ypT2N0 disease after docetaxel/ cyclophosphamide x 4.
Would you proceed with KEYNOTE 522 regimen and add anti-HER2 targeted therapy adjuvantly?
What would you offer a premenopausal woman with clinical T2N1 ER positive breast cancer for adjuvant therapy after she achieves a pathologic complete ...
What do you do if LFTs are elevated after one dose of neoadjuvant TCHP (highest ALT >13 times upper limit of normal, normal bilirubin) with prior n...
Is there a certain energy beyond which you feel the acute or late toxicity to the skin/breast warrants a switch to photon techniques?
Would you consider the discontinuation of either anti-HER2 agent or both?
I have a patient in her 60s with CHEK2 mutation, diagnosed with bilateral breast cancer. Lumpectomy showed b/l tumors <10mm both ER/PR+, HER2-, but...
In what clinical circumstances would bolus be indicated for this histology?
How do you modify your adjuvant whole breast RT design (e.g., CTV_WB per RTOG 1005 volume-based or field-based approach) for patients with *prior* cos...
If the patient has invasive breast carcinoma and close margins with no other risk factors for local recurrence, would you utilize a cavity boost?
What factors do you consider?Is your thought process at all different from your approach to boost with IDC? Do you apply TROG 7.01 data (age <...
What resection margins are required for pure DCIS with adjuvant RT? What resection margins are required for pure DCIS without RT? For additi...
Should these cancers be treated like hormone positive breast cancer or triple negative breast cancer?
She is pre menopausal with cT1c grade 2 disease...
What scenarios would you do second neoadjuvant treatment vs surgery?
Due to the use of 1-1.5 cm CTV expansions on the surgical bed, the CTV for PBI often closely approaches the skin surface. In such cases, do you apply ...
If said patient was known to be gBRCA mutated, would you use neoadjuvant chemotherapy to enable adjuvant olaparib for those that did not have a pCR? &...
What if it was found on SLNB and no axillary dissection was performed? Any risk factors that would make you consider RNI vs CW only vs observation?
Ref: Geyer et al, Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and hi...
If pCR in lumpectomies would you boost both sites?
How much of the benefit of adjuvant chemotherapy do you expect to be due to ovarian function suppression due to the chemotherapy?
How would you approach management? If a low oncotype score was obtained, would this change your management?
The tumor was initially 5.5 cm in size.
Mastectomy and ALND revealed a grade 2, ER/PR positive HER-2 negative tumor with negative surgical marg...
Is dose modification of docetaxel necessary with Gilbert's when giving TCHP?
Which agents would you select and for how long would you treat them?
If a patient presents with ER/PR positive, HER-2 negative pT1cN1 invasive ductal carcinoma with micropapillary features s/p lumpectomy, how would you ...
Patient is young and reoccurrence is one year after initial diagnosis of T1cN0 ER/PR positive, HER2-negative breast cancer treated with mastectomy, bu...
In subset analyses of OlympiA there seems to be smaller magnitude of benefit among HR+ patients. In your opinion, should adjuvant olabarib be offered ...
ER 95%
The patient is not amenable to re-resection.
What pathologic features and/or margin status would preclude the need for additional irradiation?
For example, what is the minimal acceptable distance between the medial tangents?
For example, a two week break halfway through a course of hypofractionation for early stage breast cancer.
How does a diagnosis of active RA inform your treatment approach for patients with breast cancer, if at all?
HR+ = ER 34%, PR 0%
RCB2 = no nodal involvement
Would you restart hormonal therapy in a patient with a new diagnosis of LCIS 2 years after they have completed 5 yrs of AI for stage 1A IDC in the oth...
Patient underwent mastectomy for DCIS in the setting of previous lumpectomy and adjuvant radiation for the invasive breast cancer.
Were patients with mixed histology included in the omission trials?
Are there contraindications to drugs like oxaliplatin or abraxane?
Does chronicity or severity of the patient's underlying symptoms play a role in yo...
The patient was treated with neoadjuvant cisplatin/etoposide followed by mastectomy and SLNB with a 4 cm primary and negative nodes. LVI was noted on ...
What is you decision making process in terms of the various hypofractionated regimens for WBRT supported by different trials?
When do you favor APBI?...
What constraints do you use for the contralateral breast and what will you accept?
What clinical and pathologic features - if any - would necessitate conventional fractionation?
The patient is intolerant to trastuzumab deruxtecan. In which clinical settings would you consider reintroduction of TDM1?
How would you proceed given that cT1c didn't meet the study criteria?
Currently on C2 of doxorubicin/cylophosphomide/pembro. Would you expedite surgery?
This is one of the available options in the NRG-BR007 DEBRA trial
Would you continue pembrolizumab? Would you introduce olaparib? If using both, how would you sequence?
What would be the indications for doing so?
Would you proceed with APBI, or hypofractionated whole breast RT?
Should this be sent on initial biopsy or on surgical pathology? What if an initially high risk patient has good risk findings post-operatively?What ha...
Given the CALGB 9343 trial, as well as the recent "Choosing Wisely" recommendation (https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-b...
Assume normal cardiac function and no obvious co-morbidities. No anthracycline previously due to age alone. The patient’s BRCA status is unknown...
For instance, the foci found were pN1mi (0.5 mm) deposit in 1st SNL (1/13 LN) and mpT1mi (8 foci). Would you consider single or dual anti-HER2 blockad...
Is there any utility in monitoring serum tamoxifen levels?
For instance, ER/PR >1% but <10% and Ki67 >50%
Do you allow pre-RT treatment with the CDK 4/6i and hold during RT, vs. allow concurrent with breast/chest wall RT, vs. delay starting CDK 4/6i until ...
Does availability of surface imaging (visionRT) reduce your use of imaging for setup?
Prior treatment with ipsilateral breast RT was >10 years ago
Do you approve ports daily or less often? Do you ever use CBCT?
Patient is ypT2N1
Patient has already received neo/adjuvant treatment with AC, paclitaxel, capecitabine, docetaxel, and carboplatin.
Would you consider neoadjuvant or adjuvant treatment and if so, which therapies? Patient initially had pT2N0 disease and recurrent disease is also ER+...
Patient previously received neoadjuvant ddAC-T with residual disease at surgery, followed by adjuvant capecitabine which was completed 2 months prior ...
Does not meet Olympia trial indication
The patient has tissue expanders in place and is receiving ado-trastuzumab emtansine.
Would you treat with PMRT? If so, would you target the CW and R...
In high-risk, node-positive HR+ Her-2 neg breast cancer patients who received neoadjuvant chemotherapy with residual disease, would you give capecitab...
How do you manage low libido in women with breast cancer on endocrine therapy? Other than managing vaginal dryness/dyspareunia, if just a desire/libid...
The tumor was 3.2 cm; post-op margins were negative, but <0.1 mm. The patient has excellent performance status. She will not be receiving sys...
Although these patients are included in the Danish trials, Taghian et al. & Floyd et al. both showed ~ 7% LRR in this group of patients witho...
Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...
How would you manage endocrine therapy 7 years after the original ER+/PR+/HER2- IDC, while on adjuvant tamoxifen/OFS develops a contralateral ER+/PR+/...
Do the same concerns as post-mastectomy radiation of implants apply?There are some small case series' (https://www.ncbi.nlm.nih.gov/pubmed/21346535 DO...
For patients who were not neoadjuvantly on pembrolizumab, is it safe to initiate it concurrently with radiation?
MRI pre-op did not reveal suspicious lymph nodes. Margins were negative upon mastectomy.
Are there factors to explain why MonarchE was a positive study and PALLAS was not?
Our breast surgeons are increasingly using Wise-pattern mastectomy for improved cosmetic outcomes. Expanding the scars by 2 cm, especially along the i...
Would you prefer APBI or mastectomy in this situation?
If biopsy is not feasible, should these patient be treated as cN+ with neoadjuvant chemotherapy or as cN0 with upfront surgery with axillary sent...
The patient was treated for left breast DCIS 5 years ago to a dose of 5040 cGy with a lumpectomy boost dose of 1600 cGy with conventional fractionatio...
With the recently reported START (A and B) trial data from the UK, in which patients were allowed to receive hypfractionated doses to nodal regions, i...
If the patient has evidence of axillary lymphadenopathy on imaging, would that change your approach to treatment?
Would response to neoadjuvant...
If yes, do you have an age cutoff and/or surgical margin cutoff?
High-risk criteria meaning >4 positive nodes and Ki67 >20%
How does this mutation compare to BRCA mutations in terms of risk and screening implications for family members?
For example, if the lumpectomy specimen had low risk/low volume invasive disease?
The patient is pT1c ER+/PR+/HER2- grade 1 IDC, LVSI-, N0(i+) with an upper outer cavity and a ~29cm breast separation
If the cavity location is such ...
In a patient with a history of VTE (now off anticoagulants), is it safe to administer fulvestrant?
The lymph node is 4 cm and is the only site that is growing on her current systemic therapy regimen.
At what timepoint after surgery does prospective adjuvant radiation no longer become beneficial?
Given arguments exist between the FDA and ASCO, where do you stand?
If this is bothersome to the patient, are there any topic ointments or medications that can help if used?
What if the patient is refusing chemotherapy?
Given sacituzumab is an antibody drug conjugate of the active metabolite of irinotecan
In light of updated monarchE trial data, it seems a SLNB would help delineate adjuvant treatment options in this population. However, Choosing Wisely ...
Grade 2 DCIS, post mastectomy with negative margins, sentinel nodes negative
In which node positive patients will you omit the IMC when treating regional nodes?
Assume no nodal involvement.
Would you favor re-excision? If re-excision and surgery are not an option, would you proceed with radiation or observation?
If the patient had prior ...
Do you boost when employing this regimen?
How and when do you plan to perform HER2 testing in patients with NSCLC?
Many of the patients on ASCENT trial were heavily pre-treated and require growth factors. With the day 1,8 treatment cycle, is there a way to minimize...
Would you recommend a re-excision?
Is radiation without re-excision appropriate; if so, should a boost be given?
For example, if they were triple negative or had a poor response to neoadjuvant chemotherapy in the breast?
How does trastuzumab deruxtecan compare to other HER2 targeted strategies?
Does anyone have experience re-treating the axilla and what dose/fractionation would you recommend?
BRCA mutant, ER/PR positive and HER2 positive T2N0M0 breast cancer diagnosed 5 years ago, treated with bilateral mastectomy, BSO, 1 year of adjuvant a...
If so, how long after phototherapy (eg. NB-UVB) is it safe to proceed with RT?
See: Systemic review of phototherapy for pruritic skin disorders
For patients with hormone negative breast cancer and HER2 positive only by copy number, do you give TDM1 for residual disease or capecitabine?
No oncotype was sent on the original breast cancer.
Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use?
Do you feel the dosing used in...
Do you deflate to a specific volume?
If using boost, how would you define the tumor bed?
Would you consider resimulation for target localization? If so, what is the maximum interval of t...
Is the competing risk of a distant recurrence too high to justify doing radiation?
Is there data to guide you? Is there any reason to believe that there is an increased risk of complications in patients with prior breast implant from...
Given seemingly improved efficacy in ASCENT patients who had less prior treatment, would you consider use after only one prior agent rather than two? ...
Are there specific patient cohorts in whom you will more preferentially use sacituzumab govitecan?
Can data from ASCENT be applied to patients with C...
This situation can feel uncomfortable. Would this feel safer if patient is s/p mastectomy and had TNBC?
Largest invasive focus is 0.4mm
Are there differences in outcome among the BRCA mutated subgroup, or others?
To what degree do you factor in patient preference when choosing among available treatments? Are there features of each regimen that you emphasize in ...
No tumor at ink? 1-2mm?
For example, does a higher recurrence score influence your choice of TC versus AC-T? Or your choice to add ovarian suppression to a premenopausa...
CNS recurrence occurred within two years of prior neoadjuvant therapy
If blood counts are sustained, do you continue or delay?
If yes, how do you modify your margins?
How can you change the minds of community surgeons who refuse to place them citing patient discomfort and for...
In which situations would you consider this a reasonable treatment option?
NSABP B51 and B52 specifically prohibit this.
Would your recommendation change if patient had complete response to neoadjuvant chemotherapy in breast and axillary nodes?
Please include informatio...
The recently published SSO/ASTRO/ASCO consensus guideline on DCIS states that "a 2 mm margin minimizes the risk of IBTR compared with smalle...
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
Genes such as ATM, CHEK2, PALB2, RAD51C/D, BRIP1 seem to show some potential increased risk of ovarian cancer. Should these patients under prophylacti...
What about a higher penetrance PV such as PALB2?
See JCO OGR 8/2021 by @Mark E. Robson discussing management of non-BRCA pathogenic va...
What normalization do you choose, what is your preferred target volume coverage, and how do you assess for homogeneity and heterogeneity?
In a scenario where patient's other clinical/familial risk does not sufficiently qualify them?
See JCO OGR 8/2021 by @Mark E. Robson discussing manag...
Specifically do we know by how much each intervention reduces the risk of developing MBC or increase breast cancer specific as well as overall surviva...
The patient is treatment naïve and asymptomatic. She also has disease in the body (bone and liver metastases).
Would you use 10x and 15x in your fields?
The patient initially received definitive therapy with AC-T and RT to the breast as well as RT to a solitary bone lesion. She has been on AI for the l...
Does skin reaction at the time of starting the boost guide the decision to bolus?
The patient has extensive liver metastases and a high bilirubin. She has not received any prior systemic therapy in the metastatic setting.
The patient has an intact uterus and has failed all available AI therapies due to multiple intolerances.
Do you allow patients with breast cancer on tamoxifen to use black cohosh?
Is there data that it actually helps?
Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
Patient was on tamoxifen when progression occurred; unable to tolerate adjuvant AI.
How would this affect adjuvant radiation plan in breast conservation therapy patients and mastectomy patients?
Will you incorporate carboplatin into the backbone as it was done in the KEYNOTE trial?
Patient had an initial tumor response to TCHP, but still had significant residual disease present, including positive lymph nodes and residual breast ...
Is there often discordance with LVI status in biopsy vs. mastectomy such that biopsy resulting as LVI negative is not reliable to decide on PMRT indic...
Do you have a specific age cutoff?
The patient was started on chemoimmunotherapy 3 years ago. Recent scans show small treated brain metastases (s/p RT several years ago) and no disease ...
Presuming that work-up for cardioembolic sources is negative, how would you proceed?
Patient with T2N1 disease and isolated liver metastases. Axilla and liver completely responded to chemo + IO, but limited residual breast enhancement ...
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
Does the answer change on proximity/distance from breast (i.e. what if pelvis or lower extremity?)
No sentinel lymph node biopsy was performed
How would the use of Oncotype guide your management in the neoadjuvant setting?
Based on pCR and EFS data from KEYNOTE 522 and recent FDA approval?
Do you do any type of assessment to see if they would likely benefit from, or be able to tolerate, treatment with DIBH versus free-breathing?
Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...
In what situations would you want to include regional nodes? Particular tumor size?
Assume patient has refused surgery and additional systemic therapy.
Given that azathioprine increases skin sensitivity preferentially to UVA radiation, is it safe to continue or do you counsel any increased risk of ski...
Assume patient is otherwise a suitable candidate.
If she is over 70 and has favorable enough breast cancer to forego a sentinel node biopsy, is it reasonable to assume she does not need to have her ax...
Given that olaparib was given within 12 weeks of completion of standard adjuvant therapy on the trial, will you still offer it to patients outside tha...
What adjuvant therapies would you recommend?
The patient was diagnosed with Ewing’s Sarcoma at the age of 10 and completed 6 cycles of vincristine, ifosfamide, etoposide, adriamycin 75 mg/m...
Is there a time frame for when you may not offer post-mastectomy radiation therapy to a patient who may otherwise benefit from treatment in a typical ...
In patients who have completed all adjuvant therapy. Similar test to what is available for stage 2 and 3 colon cancer patients by Natera.
No prior radiation. No evidence of chest wall, axillary, or supraclavicular disease.
Do any studies support this rationale? Does the presence of a somatic vs germline BRCA mutation impact your decision?
What specific technique (i.e. interstitial vs intracavitary, 3DCRT vs IMRT) do you prefer? What do you consider to be the pros and cons with each appr...
These patients were not included in FAST or FAST-Forward. Can we extrapolate to the treatment of high grade DCIS?
Patient is on fulvestrant+CDK 4/6 inhibitor and with NED for 5 years. In which cases would you consider stopping CDK 4/6 inhibitor?
How would your management differ in pre- and post-menopausal females?
Would your approach differ if patient is premenopausal or postmenopausal?
Do you use no tumor on ink for margin even if DCIS is the component close to the margin?
Do you discuss patient visits and associated costs when making this decision?
We usually recommend copper IUDs, but that's not feasible in all women.
Chemotherapy is often de-escalated and omitted in this setting. Would you also consider de-escalating radiation and treating like more favorable histo...
<40y/o female w/ initial biopsy showing G3 IDC with 80% ER+, 90% PR+, and HER2 positive (IHC 2+; 1.6 HER2/CEP17 ratio and 6.3 HER2 copies/nucleus.)...
Healthy 67 y/o woman, 1.5cm tumor, grade 3
Historically, IBC is traditionally treated with trimodality therapy to include PMRT with comprehensive regional nodal irradiation (RNI). However, give...
Is there an age cutoff below which you would offer adjuvant chemotherapy regardless of Oncotype results?
(Example: A 35 y/o woman with T2N0, ER+, sen...
Given the difficulty in identifying the location of the positive margin, would you push to re-excise?
Do you match on skin? What maximum hot spot do you accept? Do you do matchline shifts to feather out the hot spot and if so, how do you do that?
Patient was given ddAC + T
Presuming that imaging does not show distant metastatic disease, what would you offer? What about if the patient were PD-L1 negative?
What is the best evidence available for the benefit of PAB in disease control?
As opposed to the every other day Florence regimen.
Would you use mini tangents, 3D conformal, IMRT?
Do you need the expander to be removed?
Would your counseling change if she reported a history of unplanned pregnancy? Is there any wording or waiver you might be able to use warning her of ...
For example, in a patient with T1 disease and 1/1 node involved with a micromet and focal ENE.
Would your recommendation change if the patient were r...
Would you use trastuzumab/pertuzumab, trastuzumab followed by neratinib, or another strategy?
Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?
Would you choose to incorporate HER2-targeting agents, chemotherapy, endocrine therapy, or a mix of these?
How does patient age, grade, histology (IDC vs. ILC) and ER status affect your recommendations
The GeparSixto, CALGB 40603, and more recently Prospero support doing it; however, it is not currently endorsed by NCCN and the latter Prospero s...
Do you find such markers such as biozorb to be more helpful than delineating the seroma and/or clips on CT?
When is this useful? During ...
Is the dose fractionation used in BR-001 (10Gyx3) appropriate for all osseous locations, for example humeral head metastases?
How would your plan differ if the patient could eventually receive mastectomy once co-morbidities improve?
Masuda et al., NEJM 2017
The IDC was felt to be a new primary arising from residual breast tissue given it was over 10 years from her initial DCIS.
i.e. 1/1 node with ECE
Would you have reservations in treating patients with breast, GI, or pelvic malignancies with radiation alone or concurrent chemoradiation?
Current guidelines for breast cancer do not recommend periodic staging scans in absence of clinical indications.
What tumor or patient characteristics lead you to consider the use of neoadjuvant hormonal therapy without chemotherapy?
Would you recommend the patient stop testosterone upon this new diagnosis? If the patient is not amenable to stopping, would you incorporate an AI in ...
How do you decide on resumption or change of therapy?
How would you approach chemoprevention if tamoxifen is
Are there particular patient characteristics (e.g. age, ER%, Ki67, grade) that make you more likely to choose neoadjuvant endocrine therapy?
Would a pCR to neoadjuvant chemotherapy change your management? (ER <5%, PR <5%)
Would you offer RT to the axilla? Would you treat the breast?
Do features such as nodal involvement, Ki-67, degree of ER positivity, etc. change your management? Would you use any gene expression assays to help y...
While we are waiting for results from B51, could we omit internal mammary radiation in triple negative, cT1N1 breast cancet pts who have a complete pa...
Would you prefer TCHP over TCH? Would you consider adding an anthracycline?
How would you approach additional systemic therapy? Would the clinical stage of the cancer affect your management?
Would you include the regional nodes?
If no anthracycline, what alternative regimen would you consider?
Comprehensice RNI? High tangents? Whole breast only? Does ER/PR/Her2 status influence your decision?
This is assuming they have other indications requiring post mastectomy radiation therapy.
For example, if partial breast RT results in the prescription dose to 80% of the breast, is that reasonable? 50% of the breast?
Is adjuvant radiation and/or adjuvant chemotherapy indicated?
Is there any safety data to proceed with TKIs/TDM-1 or to proceed as standard with THP?
For patients who remain NED for years, when would you feel it's appropriate to hold therapy?
Would you consider/favor APBI given the negative normal breast if you can meet the brachial plexus constraints?
We sometimes find highly suspicious LNs by CT, PET or MRI in the undissected regional lymphatics, and surgeons may not be willing to perform another o...
If the patient had at treatment break not due to radiation toxicity, for >2 weeks, and had to complete the remaining course, would you consider any...
Is breast conservation absolutely contraindicated? What is the true increase in risk of secondary malignancy? Is there a good reference?
What would you offer if the patient is not a candidate for cytotoxic therapy?
Would you consider an Oncotype or Mammaprint? Would your management change if the patient had 1-3 positive LNs on SLNBx (as opposed to ALND)?
The woman was on on a GnRH agonist + AI due to her premenopausal status at diagnosis and now wants to know if she continues to need the GnRH agonist.&...
Since oncoplasty is becoming more common at the time of lumpectomy, is it possible to do APBI with an HDR device like SAVI in these patients?
After multiple adjacent tissue transfers it is difficult to define a "tumor bed" with oncoplastic surgery. Surgical clips are often useful ...
Would your decision for anthracycline change if the patient were elderly?
In particular, I have a patient who underwent lumpectomy for a T3 tumor with positive margins and 1/2 SLN+. She is now scheduled for mastectomy ...
What technique/schedule/material?
Would you send Oncotype during chemotherapy if not sent already? Would you stop adjuvant chemotherapy if a prior Oncotype was 25 or less?
Patient has progressed through prior lines of endocrine therapy.
For patients with low risk, early stage, HR+/HER2- breast cancer who initiated endocrine therapy in order to delay their surgery due to the COVID 19 e...
What is your specific therapy choice and duration?
Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?
I know that many advocate using vaginal estrogen in this situation. Most of the studies of vaginal estrogen in this situation have been small an...
Would you consider gene profiling to determine need for chemotherapy?
Knowing the differential effect seen with menopausal status in RxPONDER, would you avoid chemotherapy or still offer chemotherapy, given that only 15....
Would you recommend re-excision or proceed to adjuvant therapy if the tissue margin is negative? Pathologist states that tumor foci at margin was only...
How would you balance the competing risks of these two diagnoses in her treatment?
Patient had a clinical T2N0 cancer at diagnosis, completed 6 cycles TCHP, and had 0.2mm residual disease with 80% cellularity, negative sentinel node.
Do you have any experience with intra-pericardial chemotherapy administration, and if so, in what cases?
Referring to a high risk patient with cT3N1 disease and ypT2N0 disease following neoadjuvant chemotherapy.
Any difference in recommendations if the patient was asymptomatic from her metastatic ER+ disease? (eg bone mets)
How do clinical risk and Mammaprint/Oncotype scores affect your decision?
For example, will you recommend a certain vaccination timing in relationship to their treatment? Any concerns for reduced immune response or risks of ...
Or the converse: changing to IV formulation after starting on subcutaneous pertuzumab/trastuzumab?
Conversely, is there any situation where you would prefer the IV over the subcutaneous formulation?
What is "clinically significant" lymphvascular invasion? What are the standards for focal vs multifocal vs embolic vs extensive? How does this serve a...
If there are small but numerous nodes involving levels II-IV and V on the ipsilateral side would you treat the lymph nodes if they had not previously ...
ASCO 2016 guidelines specified that SLNB was not recommended for T3/T4 N0 patients but uptodate allows it.
Is there a distinction between these tumors and patients with breast cancer with neuroendocrine features?
Given that trials excluded patients with low ER, PR for this approach.
Given the data from KEYNOTE-522, would you try to incorporate chemotherapy in the treatment regimen?
In the case of conventional fractionation or SBRT, would you constrain the implants? (No history of breast cancer.)
What schedule do you use?
Does tumor size impact your recommendation? High grade? Young patient age?
Would it affect your decision whether original primary tumor and treatment was hormone positive or negative?
TBI was 20 years ago, chest wall RT was 8 years ago. The solitary nodal recurrence in axilla was resected, but with ENE+, PNI+, with no further ...
For example, in a young high risk patient who completes less than half of her prescribed treatment and wants to resume after a period of months, how w...
2 populations of cells with 95% negative by FISH (ratio 1.07) and 5% positive by FISH (ratio 10)
Do you consider placing an Ommaya for IT chemo with methotrexate or cytarabine? Knowing that leptomeningeal carcinomatosis carries such...
Based on MINDACT update from 2020, a 5% difference in DMFS for patients 50 years or younger was noted, favoring treatment with chemotherapy (93.6%; 95...
What considerations do you take for post-lumpectomy radiation and endocrine therapy?
The trial included only a small percentage of these patients.
Does lymph node positivity change your management?
Would you consider ALND and /or XRT to axilla?
For example, ultra-hypofractionated whole breast RT?
Options:
1) ddAC-T- surgery- adjuvant capecitabine if residual disease
2) weekly taxol/carbo x 12 followed by dd AC x 4
3) Keynote 522- pembro/taxo...
Patient case is triple positive inflammatory breast cancer
Are there any studies that compare them?
For breast patients being treated in prone position. The plans generally spare the skin more so than in the supine position. If a patient has a ...
Initial presentation was stage 1 treated with lumpectomy and whole breast radiation.
How would your treatment change given pCR rates are reportedly much lower in triple positive patients?
Would there be concern that the false negative rate be too high with a SLNB alone? Is this mitigated by having the clinically involved node clip...
Of note, the patient received cytotoxic plus HER2 directed adjuvant therapy but declined endocrine therapy.
Mini-tangents only? 3-4 fields including lightly weighed perpendicular to chest with some exit dose to lung?
Are there exercises, massage techniques, or support garments that are effective at preventing or reversing lymphedema of the breast?
If no surgical LN evaluation is performed, how do you determine what volumes to include in your radiation fields?
Initial treatment with Taxane-Trastuzumab-Pertuzumab with then maintenance with the two anti-HER2 agents and and an aromatase inhibitor. Would you bio...
For example, in a woman who is post-mastectomy with early stage pleomorphic ILC with ITCs in a sentinel node, would the histology push you to recommen...
Patient is on anti-hormonal agent (exemestane) with anti-HER 2 agents (trastuzumab and pertuzumab)
(e.g. bulky supraclavicular, internal mammary, as well as retrosternal lymph nodes)
Do you adjust dose/fractionation?
She had already completed ddAC and two cycles of paclitaxel before the reaction.
For example: do you use docetaxel + cyclophosphamide (TC) x4 and what is the evidence for using such a regimen
surgically confirmed node negative disease
For example, would you consider high tangents in a patient who did not undergo SNB due to age and comorbidities, but has high risk features such as gr...
Recent EBCTCG meta-analysis published in Lancet 4/2023. https://doi.org/10.1016/S0140-6736(23)00285-4
ACOSOG Z11102 mandated radiation with a boost. Hypofractionation was prohibited. This isn't how we practice nowadays and some women might otherwise me...
If the oligometastatic lesions are not longer PET avid after neoadjuvant chemotherapy, would you consider further treatment with local therapy or obse...
Do you repeat the loading dose of trastuzumab?
Do you contour cardiac vessels and/or heart substructures? If so, which one(s) and what dose tolerances do you assign them?
e.g. Gingras et al., JNCI 2017, a secondary analysis of the ALTTO trial?
Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...
If a SLN biopsy could not be performed and only a few lymph nodes were removed by ALND that were negative, would you treat the nodes? What facto...
How has your practice been impacted by the ECOG 2108 (Khan et al. ASCO 2020 Abst LBA2)? Are there sites or distribution of disease that prompt you to ...
Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.
Since only part of the breast was treated before, would you include treatment of the whole breast now, despite no detectable disease?
The treatment of ITC and micrometastases in lymph nodes in women with breast cancer is controversial. Given the rarity of male breast cancer, complex ...
BRCA status unknown currently
High risk meaning LVI, triple negative, Grade 3, etc?
For intact breasts, should adjuvant radiation to the lymphatic drainage be added to breast radiation?
Given the changing landscape of treatment, some patients may have already received capecitabine previously. Would this impact your treatment rec...
Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?
Would your answer change if the new lesion is ALH/ADH?
Would you consider use of immunotherapy with checking PDL1? What chemotherapy agents would you consider along with mastectomy/radiation?
What do you do/say when a discussion of evidence-based information doesn't convince a patient that this is her best chance of cure? Some patients even...
Is age solely indication for boost irrespective of other factors?
Interest in approach for elderly population especially
Would you consider an anthracycline based substitution vs changing to nab-paclitaxel or a combination with platinum agent?
Would you choose a platinum based agent? Other chemotherapy combinations?
Chemotherapy - Carbo/Gem (2nd line). PDL1 and BRCA negative.
Has anyone omitted post path fracture radiation of pelvis/long bone in favor of starting endocrine treatment first? Or would one omit RT and start a C...
Would you recommend additional cytotoxic chemotherapy and/or switch her anti-Her therapy to T-DM1?
Should the VP shunt be moved prior to RT? Are there any complications of radiating a VP shunt?
How do you counsel regarding uterine sarcoma risk?
Does margin width play a role in your decision making? Would no tumor on ink be acceptable? What if there was LCIS in the specimen as well with ...
What timeframe would you suggest to stop breastfeeding? From affected breast or both breasts?
Would implant reconstruction prior to radiation therapy change your recommendations? Would you ever treat just the nodes and omit the chest wall/recon...
Especially if HER2 negative on pathological specimen
Are there specific considerations you/your tumor board take into account?
Asymptomatic brain progression despite CNS surgery and SRS x2 over the past 2 years.
If a patient meets all omission criteria per CALGB and PRIME except age would you consider omitting RT? Is there any evidence for such an approach?
Progression was observed only in the breast and required palliative mastectomy (T4b TNBC)
She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?
Patient completed adjuvant AC-T 8 months prior to recurrence. BRCA negative, foundation medicine NGS pending.
PD-L1 is low and she has residual neuropathy from neoadjuvant paclitaxel.
Would you boost the area of positive margin? Would you include the expander?
Would you have CT surgery resect the mass, followed by adjuvant radiation?
Assuming the patient is otherwise a candidate for APBI.
Do you use a standard margin around the mastectomy scar (ie 2cm sup/inf), or do you extend the field to include the entire chest wall?
For example- do you have experience using a LHRH agonist along with tamoxifen?
While the KATHERINE trial for HER2+ used path staging, CREATE-X for TNBC with capecitabine used the Japanese Breast Cancer Society response criteria. ...
How do the recent results from E2108 impact your practice? Would you consider locoregional therapy in patients who are good responders, have oligets, ...
How about in the setting of treatment after recurrent resected disease if it didn’t involve the skin: would you push for coverage even though pl...
Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.
Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?
In cases where patient received 6 cycles of THP and 1 year of HP
Patient received adjuvant chemotherapy and anti-Her2 therapy 3 years ago.
If yes, would you offer tamoxifen or ovarian suppression plus AI?
Or would you only irradiate the axilla?
Received adjuvant HER2 directed therapy 3 years ago.
< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.
Would you consider still immunotherapy even if aggressive disease vs single agent chemotherapy?
For instance, patients with ATM mutations
If so, please describe your experience and dosing.
Does the SYSUCC-001 trial presented at ASCO 2020 change your practice?
If the cancer was also HER2+, would that influence your decision?
This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...
Would you modify your dose if there was overlap from the prior treatment?
In a patient with early stage breast cancer that would otherwise require radiation, would you recommend treatment if the patient has active skin lupus...
What are the differences that a patient may expect with HDR vs LDR brachytherapy?
What if ALND reveals no residual disease?
Would you consider reirradiating the breast and regional nodes? Further axillary surgery? Partial breast radiation? Or other?
Patient previously received neoadjuvant carboplatin, anthracycline and taxane regimen and is BRCA negative.
Would the degree of response (pCR vs no pCR) influence your decision making?
i.e. FAST-Forward: 26 Gy in five daily fractions?
How would this change if the patient had metastatic HR+,HER2- breast cancer and now has symptomatic pancytopenia secondary to BM involvement after TCH...
She has received 4 cycles of AC with no clinical response and is now pending completion with Taxol.
Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?
T1a - 2mm; N1 - 1 ipsilateral lymph node measured 6mm
Oncotype says too small to test and NGS says too few cancer cells to determine status.
What chemotherapy regimen would you recommend?
If so, do you give RT before or after adjuvant chemotherapy?
Radiation in the setting of positive margins is sub-optimal and from my understanding high boost doses do not replace further surgery. Is it better to...
How does gBRCA status impact your decision?
Would your choice vary based on the patient's gender?
Many hormone positive patients are beginning hormone therapy until they can go to surgery. With a prolonged pause in routine procedures seeming very l...
Would the recommendation differ based on HR+ vs. TNBC vs HER2+ classification?
Would you recommend against immediate breast reconstruction?
Would you consider delaying chemotherapy and proceeding only with endocrine for now?
Do you consider this regimen based on the 10 year results of the UK FAST trial?
Initially treated with anastrozole, current treatment is with fulvestrant.
Personally, my practice is to guide patients directly to surgery or to do neoadjuvant chemotherapy rather than to do neoadjuvant endocrine therapy, bu...
For example, if you had a triple positive breast cancer found on breast biopsy and repeat ER/PR/HER2 testing at the time of surgical resection showed ...
Is it possible to get a good measurement with TLDs? TLDs can overestimate the surface dose by 10 - 40%. Do you use a skin diode measurement on the fir...
Would your practice vary based on hormone receptor or Her2 status?
When a physical exam is important and telehealth is not a good option, should we be proactive and reschedule or should we continue to see them as sche...
Would you incorporate platinum into your treatment or enroll in an adjuvant IO trial?
No primary identified in the contralateral breast. No distant metastasis identified.
Do you send multiple Oncotype testing for each sample in a multifocal or multicentric breast cancer?
Tumor size and grade meet criteria for oncotype testing in all foci.
IHC: ER 70%; PR 70%
OncotypeDx: ER - Negative; PR - Positive
Patient received anthracycline and paclitaxel for HR+ breast cancer in the past.
i.e. T1, low grade, ER positive, margins negative, older age?
If a skin flap was required due to necrosis after the mastectomy, would you still provide PMRT assuming the patient is high risk?
Do you proceed with Paclitaxel or go to surgery instead?
Would you consider VMAT or protons?
ie, not a classic NTRK3-ETV6 fusion.The patient has progressed through CDk4/6 inhibitors and intolerant of alpelisib, and does not want chemotherapy.&...
She has no other site of disease progression and has been on an aromatase inhibitor (progressed in the CNS while on a study with adjuvant abemaciclib)...
The APT trial reported excellent DFS, OS and RFI for tumors <=3cm but few were smaller T2s (2-3 cm) and few were >70 years old.
Stage T1bN1mic
Given the recent results of the NRG/RTOG 1014 trial, would you consider it reasonable to offer breast conservation for women who meet the trial entry ...
Assuming the patient is not a candidate for SRS
In a patient with a positive SLNBx, would triple negative or Her2+ status affect your decision on whether or not to proceed with a full ALNDx?
This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.
Is surgery preferable? What dose/fractionation would you recommend?
Pre-treatment estradiol: <5
Estradiol after 1 yr: 35
Would it be acceptable to treat a patient with locally advanced breast cancer (ex pT2N2a) s/p lumpectomy with a short course 4 week treatment ins...
Generally, the margins are uncertain in this scenario and re-excision is usually not possible.
For example, if a patient had testosterone pellets injected, perhaps making endocrine therapy less efficacious, would that sway you to use chemo?
Being that this is a favorable histology would you use Oncotype Dx to help decide on neoadjuvant chemotherapy? Would you recommend neoadjuvant endocri...
Would your decision change based on the patient's clinical nodal stage?
https://www.ncbi.nlm.nih.gov/pubmed/31838010
Does the KN-522 data change your decision about chemo regimen?
In the absence of side effects, would you be inclined to continue beyond 10 years as chemoprevention? Would you factor an intermediate/high oncotype R...
Would you treat this differently than someone who only presents with axillary nodal disease?
How would you manage symptoms? How would you adjust the adjuvant regimen (dose reduce, omit paclitaxel etc)? What strategies would you consider for pr...
This is a patient with a 1.8cm node negative HER2 positive tumor that is grade 3, high Ki67, and ER positive.
Data presented at the 2017 SABCS (abstract GS1-01) of the EBCTCG meta-analysis stating a benefit of dose-dense chemotherapy applies to ER positive and...
Z11 and AMAROS tell us that in cN0 patients, an adequate ALND is considered definitive treatment, but what about patients who have low volume biopsy p...
Germline genetic testing negative
Would you offer definitive radiation? If so, what dose and technique?
What size cut off or other factors (i.e. LVI) do you consider? Do you only treat IMN and medial SCV vs include entire axilla if only SLN?
Assuming there is no other locoregional or distant disease. Would you treat the entire contralateral chest wall? Nodes?
Are there clinical scenarios in which 5 years of tamoxifen alone remains sufficient?
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Would you offer AI + OFS or tamoxifen to a woman with a grade 3 T2N0 tumor and OncoType of 15?
Additionally, would the finding of any mutations, such as ESR1, change your recommendation?
Due to respiratory motion and resolution of the lesions on re-staging imaging, targeting the lesions on CT sim is extremely difficult. Also, is consol...
Do age or margins factor into your decision making? What dose and fractionation would you use?
Would you recommend it for a mammographically occult primary or if the patient had dense breasts? What if a high risk patient decides not to hav...
History of Multiple Myeloma with renal failure currently on velcade.
For example, is this still your approach in women with small tumors or node negative disease?
Example: Low grade mucinous tumor post bilateral mastectomy
2D Echo - Normal Ejection Fraction
Would you offer adjuvant chemotherapy to a post-menopausal woman with a BRCA2 mutation and a T2N0 ER positive breast cancer with an oncotype of 12?
It is included in favorable histologies on NCCN, but no mention of how to treat based off HER2 status.
Patient only had upfront surgery.
Let's assume genetic testing will not be done.
She had disease progression on palbociclib and letrozole. She also has a PIK3CA mutation however did not tolerate alpelisib due to Grade 3 hyperglycem...
How would you specifically treat a grade 1, but HER2 positive lobular?
What are the indications for local control of the breast in patients with metastatic breast cancer?
Do you still follow the atlas guidelines and contour the breast to the latissimus muscle laterally the the pectoralis muscle posteriorly or since the ...
Patient has grade 3, pT3N0 disease and is s/p lumpectomy.
PDL1 status pending; BRCA wild type
Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...
Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?
Alliance Z-1071 cohort had 5% with cN2 and <1% fixed or matted and the current Alliance trial 011202 only allows cN1. ALND has never been shown to ...
If there is a pCR in the breast and nodes do you treat the breast/chest wall SCV and full axilla? IMNs? Would the type of surgery (lumpect...
Does the results of the tnAcity trial influence your decision in choosing a 1st line option?
Status post nasolacrimal stent with improvement. Would you re-challenge or permanently discontinue docetaxel?
More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?
Do you think about it in the same way as DCIS in terms of radiation decision making (i.e. grade, margins, age of patient)? Is Paget's disease le...
How would you figure out how to treat someone with a prior localized HR+,HER2- breast cancer treated with adjuvant AC-T (5years ago) and a recent ipsi...
For instance, would you be more inclined to treat a patient with T3N0 disease and no other risk factors? What if there were a small neighboring ...
Would you consider an aggressive approach with RT and/or surgery to the bone lesion and treat the primary as locally advanced breast cancer?
Do you use anti-hormonal therapy for these patients?
Role of neoadjuvant TC vs. anthracycline based regimen?
What risk do you quote for contracture or failure? Does the type of implant or age of implants matter?
How would you approach a post-menopausal woman who now wishes to start adjuvant endocrine therapy more than 3 years since surgery?
Would you prefer first-line AI/CDK 4/6 inhibitor, or first-line AI followed by 2nd-line fulvestrant/CDK 4/6 inhibitor (either abemaciclib, once availa...
Is this new SSO choosing widely guideline being widely adopted and are there any concerns regarding this for clinical practice?
Does your recommendation change for women with HER2- disease?
If finished adjuvantly, what would you do -- continue TC or change chemotherapy?
For instance, in a woman with small volume disease in the breast, is your posterior border still the lung interface? Do you cover all drain site...
If yes, would you still recommend dual HER2 directed therapy?
After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...
Rationale for adjuvant therapy was high Oncotype score.
What high risk pathology factors would you consider in making your decision one way or another?Would it matter if this patient was elderly vs young? W...
Given that DBA is associated with increased incidence of MDS, AML and other solid tumors, would this modify your treatment recommendations?
For early stage disease in a single breast, would you consider neoadjuvant chemotherapy or upfront surgical staging followed by adjuvant therapy? What...
RP node with treatment related changes and surgical specimen from TAH/BSO no other foci of malignancy found.
Do you tailor treatment to a goal response? Do you refer to data illustrating improved prognosis if the patient develops a CR or PR?
Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...
Could carboplatin be considered here? Or any evidence for a PARP inhibitor?
Liquid biopsy also showed AR amplification.
If so, after how many cycles of chemotherapy would you switch?
PIK3CA and ESR1 mutations on NGS without other targets and who has progressed on CDK 4/6 & AI and several single agent chemotherapies. Aside...
Does hormone receptor status impact your decision?
Would T stage, Oncotype or any other factor affect your decision?
For example, for T2N1a ER+ disease? Or would you offer PMRT and axillary nodal irradiation (as a replacement for ALND)?
What would you use either in adjuvant setting or in metastatic setting?
Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.
I have seen some advocate for this in the community, although a Cochrane metanalysis did not find an advantage to giving the taxane earlier.
In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...
In a patient with their second cancer, with oligometastatic disease, do the risks of RT related second malignancies outweigh the benefits?
Would you forego anthracycline?
Neratinib was studied following adjuvant trastuzumab. Do you extrapolate that data to give neratinib to patients who have received adjuvant T-DM1 inst...
The ABC trials (Blum, JCO, 2017) used six cycles of TC. Is it because of the superiority seen with TC x four cycles versus standard AC x four cycles (...
Often patients are referred to medical oncology for adjuvant therapy for early stage breast cancer after BCS and just before starting radiation.
What techniques are most effective to minimize contralateral breast, heart, and lung dose? Do you recommend conventional fractionation?
Do you see a role for adjuvant radiation therapy?
Assume the patient had axillary lymph node dissection and taxane chemotherapy. How would you counsel the patient about risk of lymphedema?
These patients were excluded from the SOLAR-1 trial.
Tumor measured 3 mm.
She developed biopsy proven skin nodules while on paclitaxel. PDL-1 positive and BRCA negative. Would you consider atezolizumab with a different agent...
Are there any quantitative measures that you use to help select patients such as breast size or heart dose? Or do you use a case-by-case qualita...
She is otherwise asymptomatic and no LFT abnormalities. Would you switch to chemotherapy or offer different endocrine therapy?
For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...
Patient has hot flashes.
Does the permanent implant change your dose?
Do you follow invasive or DCIS guidelines? Would you consider re-excision in a patient with multifocal microinvasive carcinoma of the breast arising i...
Would you recommend observation? Whole breast irradiation? APBI?
Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?
If so, would you treat as node + BC with anthracycline and taxane regimen or non-anthracycline regimen (i.e docetaxel and cyc...
She developed isolated paraspinal recurrence that is not amenable for local therapies including RT.
Patient defers chemotherapy. She is currently on anastrozole/Herceptin and perjeta with a response but it is suboptimal. I would like to add a CDK 4/6...
The patient received THP and now is on maintenance HP when she developed CNS disease.
She had a ipsilateral chest wall recurrence after mastectomy ~5 wks after surgery that was known TNBC. Residual disease remained in known breast and a...
Initially stage 1 disease with high risk Mammaprint recurrence risk completed adjuvant chemo 15 months ago.
What is your preferred approach to PMRT with inflammatory breast cancer with adverse risk features (i.e. age <45, close/positive margins or poor re...
Data was presented at ASCO in 2017 that abemaciclib has brain activity in HR positive breast cancer.
She had not received any systemic therapy previously.
Most guidelines recommended adjuvant chemotherapy if tumor size was >3cm at the time of TAILOR Rx and patients with tumors >5cm were not include...
greatest measuring 1.0cm.
What if this lesion was at the top of the hair bearing skin of the axilla?
Or would you proceed with standard-of-care adjuvant approach for high risk patients?
How would you dose?
The use of neoadjuvant CDK 4/6 inhibitors is not standard of care, but there are clinical trials looking at this question and patients who are chemoth...
These devices give off a significant amount of artifact on CT and some devices say they are a relative contraindication with adjuvant RT.
AI+ CK4/6 inhibitor? Fulvestrant + CK4/6 inhibitor? AI + fulvestrant? AI + fulvestrant + CK4/6 inhibitor?
I.e. according to Mammaprint test?
Would it make a difference in terms of OS if the patient received AC?
Do you use portal or orthogonal imaging or both?
Would you proceed with modified radical mastectomy followed by systemic therapy, or would you consider neoadjuvant therapy? Would biomarker status mat...
Does the presence of N1 disease push you towards offering chemotherapy or would you continue endocrine therapy based on the PR?
What is an adequate dose to the skin?
In addition to gabapentin and Lyrica, what else can you do for chemotherapy induced neuropathy?
Favored approach: AC-T +\- carboplatin, +\- gCSF
If so, what clinical indications? Are there any advantages of VMAT? Thoughts on concerns regarding lung and heart dose constraints?
Or would you offer high tangents with hypofractionation?
Some oncologists wait 1 day, 1 week or 1 month? Is there a preferred waiting period?
What size of DCIS would make you concerned? Would you estimate the risk of recurrence with and without radiation?
Would a limited axillary dissection influence your decision? Any other risk factors that would sway your decision?
The patient has been off her AI for two years.
What's the minimum isodose coverage line you accept for coverage of higher level axillary lymph nodes?
She has hepatorenal failure due to metastatic disease.
Does the T stage influence your decision (for example, T1mic)? Would multiple positive nodes showing isolated tumor cells sway your decision? Would a ...
Do you always recommend treating breast cancer patients with getting reconstruction with their tissue expanders in place? Or is there a scenerio you w...
NSABP B-39/RTOG 0413 prescribed a dose of 38.5 Gy using two fractions of 3.85 each daily, but prescribed to the ICRU 50 reference point dose (usually ...
Is it necessary to irradiate the breast?
Have you used anti-androgen therapy? Do you enroll patients on a trial or treat off label?
Patient will receive adjuvant xeloda.
An ASTRO APBI update readers are warned “the combination of IORT and WBI should be used only with caution and limited to women with higher risk ...
NCCN states that daily imaging is discouraged but in practice many radiation oncologists are doing daily cone beam for non-IMRT breast
No viable cell was present.
There have been case series published on this topic (most recently, PMID:26853347) with reported depigmentation within the RT treatment field.
What factors influence your decision?
Which patients should receive TDM-1, Trastuzumab+Pertuzumab or Trastuzumab alone?
Assume you have good margins and the cavity abuts the implant. Are there any specialized techniques that you would recommend?
In obese patients, would it make sense to switch from a GnRH agonist to an antagonist based on the data from the recent JCO study of dagrelix vs. trip...
Do you use NRG/RTOG, IMPORT LOW, single institution data, or retrospective data?
NCCN recommendations seem to mention these patients as not candidates for preoperative systemic therapy if the invasive carcinoma extension cannot be ...
Patient did not receive neoadjuvant therapy.
What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...
An example of an air expander is located at:
https://www.airxpanders.com/index.php
How do you ensure accurate dosimetry with the use of air ...
Clinical T1c patients were included in the KATHERINE trial that often are treated with adjuvant paclitaxel and trastuzumab
Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?
Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...
If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?
The ABC trials show a DFS advantage of anthracycline-based regimens. Would age alone procure you from using it in a patient?
Specifically, any data or experience regarding Ehlers Danlos syndrome?
Any factors that would impact this decision (how far along adjuvant trastuzumab, disease characteristics, etc)?
This patient is a young lady with stage IV ER/PR positive, Her2 negative with oligometastatic breast cancer undergoing a planned bilateral oophe...
E.g. for lobular, etc.
How would your radiation targets change? There are not recommendations for intramammary nodes in guidelines.
The CALOR trial included patients that could receive HER2-targeted therapy.
Only a small subset (22-24%) of patients in Katherine trial received a non-anthracycline containing regimen.
Can repeating Oncotype on a locoregional recurrence show a change in the biologic behavior of the cancer over time and guide treatment decisions?
The recurrence was 2 years after treatment with ddAC + T. If you elect for systemic therapy after local therapy, what chemotherapy would you use...
If the patient meets the CALGB criteria for the current cancer, are there situations where you would omit RT in a patient who has never had RT? What i...
Would you recommend mastectomy? What would you irradiate? What are your fields?
Updated NCCN guidelines say there is no data to support radiation for pleomorphic LCIS. Previous discussion recommended radiation for LCIS https:...
If planning standard fractionation, what factors would you consider in omitting a boost (ie age, LVSI, etc)?
The patient completed AC-T three years prior.
Which do you favor, if so?
https://www.abstracts2view.com/sabcs18/view.php?nu=SABCS18L_568
Any concerns regarding toxicity with APBI?
Assume she refused enrollment on B51.
Would you consider neo-adjuvant chemotherapy or treat with endocrine therapy?
One such patient progressed through trastuzumab/pertuzumab/letrozole and TDM1 alone. How would you combine ER+ approaches (eg CDK 4/6 inhibitor ...
What patient and disease factors may influence your decision?
Do your recommendations differ if patients are pre or postmenopausal given the data?
What factors influence your recommendation?
If a patient is on rituximab for multiple sclerosis, do you recommend a particular fractionation to minimize chance of MS flare during treatment? If a...
Would you recommend a patient get mastectomy to avoid radiation? If treating a breast cancer patient with ILD, what lung dose constraint do you use?
For instance, in stage III, would you use chemotherapy in neoadjuvant or adjuvant setting? What regimen would you use?
For example, in a patient > 70 years old?
rad50 is a key DNA repair protein.
Have the results from IMpassion130 changed the standard of care?
She otherwise does not have any BRCA mutations nor any underlying cardiac disease.
If a patient is due for their yearly mammogram on the breast that has been diagnosed with cancer but is still undergoing active treatment (chemo or ra...
And how long? According to the ABCSG-16 Trial there was no difference in extending AI beyond 2 years after an initial 5 years.
Will you incorporate the results from KATHERINE into clinical practice now?
The CREATE-X trial did not include HER-2 positive patients but the ER-negative population benefited from capecitabine. Would you consider capecitabine...
Hormonal therapy would not be tamoxifen.
Does the answer vary based on whether it is neo/adjuvant or metastatic setting?
How applicable is the SOFT/TEXT data in this setting ?
Would you do anything different than usual regarding bolus, energies, skin dose desired for post-mastectomy chest wall radiation if a nipple-sparing m...
Is there concern for increased risk of chronic nipple pain with NAC in the boost field?
Analyses have showed questionable benefit with chemotherapy
One example is the original breast cancer ER high 90%, PR mod to high 40%, Her2 negative. A liver metastasis diagnosed 2 years later showed ER l...
What are your thoughts with the new KEYNOTE-522 regimen? Would you just use carbo/paclitaxel/pembro part of the regimen or give as much doxorubicin as...
At what energy of electrons would it be better to use photons? How many fields and what field angles should be used for photon boosts?&nbs...
OS benefit was limited to patients with endocrine sensitivity, defined as either a documented clinical benefit (CR, PR, or SD for ≥24 weeks) f...
Assume patient cannot do DIBH. Would techniques would you use to meet dose constraints? What minimum dose would you recommend?
What techniques have you used to evaluate for field overlap given the different setups? We have used a thick wire placed at midline during the verific...
Assume each primary meets ASTRO 2018 guidelines
What is the ideal timing for monitoring and what laboratory tests should be used?
Initial pathology additionally yields low Ki-67 and is HER2 negative.
Per NCCN guidelines, SLNB after neoadjuvant chemotherapy is preferred.
Would multifocality, multicentricity, LVSI, N1mi, etc affect your decision making?
Results for oncotype Dx are not always available readily.
Assume the patient has bone only metastses and will be on hormonal therapy
If a patient has early stage disease with peau d'orange but does not meet criteria for inflammatory breast cancer, is PMRT indicated?
Does an age over 70 years, size, histology and hormone receptor status affect this decision?
Should LVI be considered present in a patient with positive nodes? MSKCC showed that LVI is a risk for LRR with 1-3 positive nodes...
Would you treat both chest walls at the same time? What fields would you use for the contralateral side: chest wall and lymph nodes? or just lym...
The patient is relatively asymptomatic.
The patient only had disease involving the right breast and axillary, cervical, and supraclavicular lymph nodes. She had complete response to with ddA...
Essentially, is there any role for "COMET trial" type therapy for a low risk elderly patient?
Is TC or CMF adequate or is only ddAC -> T recommended?
(HER2/CEP17 ratio <2.0, copy number >4.0 and <6.0 signals/cell)
There is a gray area in clinical decision making where the practice seems to be different for borderline size tumors such as a 7 mm T1b lesion with no...
If yes, what dosage and do you use it continuously or intermittently? Regarding provera, many patients with ER/PR (+) breast cancer worry about taking...
In light of the KATHERINE data- does this change your practice?
Do you test for pregnancy prior to each cycle?
What if CD4 count was low?
Particularly for patients too large for prone breast treatment, do you use a breast immobilization device or bra? Do you change your fractionat...
Several surgeons have asked this to reduce the time to reconstruction, complications like contracture, and the possibility of re-operation/failure of ...
Assume your patient did not receive radiation upfront and they had an axillary dissection due to recurrence. Would you recommend radiation? What would...
Not to decrease recurrence risk, but for chemoprevention of new ER-positive DCIS or invasive disease based on the Gail Model. If so, is there data to ...
Would your decision change if the patient is getting chemotherapy and hormonal therapy?
How does the timing of recurrence play into your decision?
In the absence of epidermal invasion and absence of dermal lymphatic invasion (DLI)
Any consideration on standard vs hypofractionation?
There has been shifting concerns with medication side effects (such as osteoporosis, blood clots), duration, and potential non-compliance.
What volumes and dose would you treat? Would you treat the regional nodes alone (including IMN)? Would you treat the chest wall?
The patient is a pre-menopausal woman with low-grade, stage I IDC who initially could only tolerate 10 mg of tamoxifen for her first year of trea...
Young woman with Her2 positive disease involving her right breast, regional lymph nodes, and liver had a CR on PET after therapy with THP and now plan...
The NEJM 2015 paper by Tolaney et al only included 1.5% of patients with micrometastases.
If a patient has ER/PR+ and Her2 positive disease in the primary tumor while axillary lymph node core biopsy is ER/PR+ Her-2 negative, do you man...
If so, what is the ideal imaging?
Assume workup is otherwise negative and she will get XRT.
Would you consider traditional breast doses or higher? Would you consider treating only the axilla if the mastectomy specimen showed widely-negative m...
Pt is healthy and tolerating Tamoxifen well.
In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...
What techniques would you use to help meet that constraint?
Can these patients be re-challenged with Herceptin?
When would you sequence radiation?
Specifically, this patient had a new left lacrimal gland metastatic lesion that developed four years from her initial diagnosis and is currently under...
If so, what is your technique?
Would you do this for ER+ patients?
According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...
How much will you weigh the demonstrated disease-free survival, including distant disease-free survival, in your recommendations?
I have a patient who will be climbing to the base camp of Mount Everest. Does a climb to 15,000 feet increase her risk? Should she wear a compression ...
V20 of 30% can be hard to attain if IMs are being treated.
What factors if any would influence your decision and what would your approach be?
Would you give neoadjuvant chemotherapy in a patient with T1 N1 M0 ER/HER-2 positive cancer if they are candidates for upfront lumpectomy?
Does it make sense to resect only the axillary nodes, but not the other involved nodal regions? Regional nodal radiation will be given.
If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?
Is there any evidence to use trastuzumab and pertuzumab without doxorubicin?
High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.
Many times we encounter patients who do not have a tissue sample readily available or in whom obtaining such a sample would be hard. On a more molecul...
What factors would you use to determine? Age, triple negative, LVSI, etc?
The patient will be planned using IMRT and fiducial placement.
The PERSEPHONE trial to be presented at ASCO suggests 6 months of Herceptin is non-inferior to 12 months in early Her2 postive disease.
What if this was an electron vs photon boost? What fractionation scheme would you use?
If so, how frequently?
Pt clinically has inflammatory breast cancer making mastectomy a poor option.
First episode was 10 years ago and patient did not receive XRT. Would you give XRT now?
If so, what dosing amd fractionation would you use?
Is breast conserving surgery followed by radiation therapy an option?
What is the optimal regimen for a pre-menopausal female with progression of ER+,PR+ and Her2 neu negative breast cancer while on tamoxifen for six mon...
Do you consider it only in lymph-node negative or up to three lymph nodes?
The patient initially had a great response to THP for four months, but now with quite a bit of lung, pleural, and nodal involvement.
Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?
Intramammary lymph node involvement has been shown to have a poorer prognosis (Hogan, Surg Onc, 2010). Would Oncotype be useful in these patients...
Inflammatory breast cancer is a contraindication for immediate reconstruction at the time of surgery, but is there a disease free interval after all t...
Would you consider capecitabine in addition to paclitaxel?
Is there any data to support this?
No prior chemotherapy.
Knowing that the analysis now is more detailed than it was 10 years ago.
What about non-Ashkenazi Jewish breast cancer patients with suspic...
Would you recommend PMRT for these patients if they did not undergo resection? Would you boost if they had other indications for PMRT?
While we await the results of TailorX, what has been the experience in your practice? If the decision for adjuvant chemotherapy is made, do you f...
Do ER/PR and HER2 markers have any role?
If so, what fields would you treat? What dose/fractionation would you recommend?
Would you use oncotype to guide your decision?
Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...
What about lobular carcinoma?
After the publication of ACOSOG Z11 we are seeing these patients in increasing numbers.
How does it vary for patients with a history of hypertension, diabetes, CHF, and coronary artery disease?
Originally received anthracycline and taxane based regimen.
Would you use carbo/paclitaxel or capecitabine or a different approach?
Do patients > 60 years old with no high risk features have any significant benefit? Has the recent update of the EORTC boost trial affected your pr...
What about tumor subtype, ie luminal A/B, Her2 positive, triple negative?
When would you omit or include a boost for DCIS after whole breat irradiation?
Should hypofractionation be avoided in triple negative disease?
In START B ~ 23 % of women received some form of cytotoxic chemotherapy, and the trial was conducted in the trastuzumab era, but there is no ment...
The Canadian trial showed conventional fractionation might be better in the Grade 3 subset, but this was not shown in the START A/B update. What can e...
Do you offer hypofractionation to younger women?
How does your approach differ due to squamous cell carcinoma histology? What are your radiation fields?
What dose calculation algorithm to you utilize (eg AAA, Acuros, etc)? Do you prefer a particular algorithm for certain sites? Do you take in...
Is there any data on safety of radiaiton with pertuzumab?
Assume no history of radiation, no evidence of distant disease and no nodal disease on dissection. Would you treat the chest wall or the&nbs...
Would a high result give you pause about omission of RT? If yes what level is sufficiently high?
What data do you quote patients with implants after PMRT?
Is there a difference among all the commercial genetic testing labs? Is there anything beyond CLIA- and CAP-certification that we should look for...
After mastectomy for the locally recurrent disease, would you consider "pseudo-adjuvant" chemotherapy for local recurrence per the CALOR trial? If so,...
Can you apply the ACOSOG Z0011 study to women who have HER2 positive disease?
Assuming the patient has N2-3 disease, would you consider omitting IMN? What other techniques would you consider to limit lung exposure?
Recent NEJM study showed an increased breast cancer relative risk in longer durations of hormonal contraceptive use that could last up to 5 years. Pre...
An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...
Pt has progressed on AI and Faslodex. Goal is radiation to axilla as a palliative intent and Capecitabine to control systemic disease.
Are you using post-neoadjuvant Xeloda based on preliminary data from the CREATE-X trial? Does BRCA mutation influence your decision?
Is there a dose constraint you are using for LV-V5?https://www.ncbi.nlm.nih.gov/pubmed/28095159?dopt=Abstract
At what point would you decide to forego local control managment (RT or mastectomy) in favor of chemotherapy alone?
If so, when? Are there certain ERBB2 mutations that would predict response to trastuzumab and/or neratinib?
Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.
Would you consider using CKD inhibitors upfront in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Hercepti...
Does resection have an impact on survival?
This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...
Assume patient had 15 nodes removed. What if 1 or 2 nodes were positive?
Would patient age factor into your decision, such as a patient <30 or 40? If you would not give RNI for a favorable pT3N0, are there other risk fac...
CALGB 9343 included ER positive patients but did not separate them out based on herceptin status. Does the study help inform their risk?
Should the patient be counseled to anticipate a worse skin reaction than normal?
Is your approach different for oligometastatic versus oligoprogressive disease? If there is concurrent locally advanced disease, would you treat simul...
Would you recommend any imaging of the axilla before lumpectomy? Would you recommend standard breast fields vs high tangents to cover the lo...
Using an AI if a woman is taking an estrogen supplement seems counterproductive.
Assuming the patient was initially treated with surgical resection and adjuvant chemotherapy followed by radiation and appropriate endocrine therapy.
What do you do with low grade (grade 1/3) tumors? In other words, does high grade pathology over rules?
Assume the patient had no radiation, what would your volumes be? Would you recommend radiation if the patient had whole breast/chest wall radiati...
In light of two phase III randomized trials showing duloxetine (S1202) and acupuncture (S1200) both improve AIMSS, which would you try first? Wou...
Would the exact Oncotype score guide your decision (ie closer 25-30 v. >30-35)? NCCN recommends Oncotype only for tumor size < 5mm but this case...
When do you institute a treatment break for skin reaction for patients who receive breast radiation?
Do concerns about matching with 3D plans justify IMRT?
Do you send Oncotype in patients with ER/PR+ breast cancer and micrometastasis in one sentinel node?
If Oncotype is high risk, what regimen of adjuvant chemotherapy would you recommend?
Would you use a regimen with lower incidence of neurotoxicity such as CMF or a taxane-based regimen with a low threshold to dose-reduce?
There is anecdotal concern regarding history of estrogen replacement therapy causing stimulation of breast tissue and therefore potentially increased ...
In other words, if there are borderline indications for PMRT (ex initial T3N0 or T2N1 disease) with a pCR, would the suspicious IM nodes lead you to o...
Would you consider using ckd inhibitors in triple positive breast cancer previously treated with chemotherapy, endocrine therapy, and Herceptin? NCCN ...
What is the maximal amount of time you would allow between the surgery the start of adjuvant RT? What other factors would you consider when deciding w...
Do you use the typical indications for PMRT (nodal status, size of primary, LVSI, age, etc)? Or, do you recommended PMRT more frequently (...
How do you approach treating ER/PR positive/HER-2 positive metastatic breast cancer? Do you combine hormonal therapy / chemotherapy and HER-2 directed...
When would you recommend that SLNB be performed prior to neoadjuvant chemotherapy? When would you recommend additional staging (completion axillary di...
We often treat elderly women with lumpectomy and adjuvant hormonal therapy without radiation. I am concerned about how to proceed after the 5 year poi...
Many women are distressed when asked to discontinue hormone replacement therapy or use intravaginal estrogen suppositories.
Some patients request chemotherapy scheduling adjustments to avoid feeling ill on major holidays. Delaying chemotherapy by a few days isn't of particu...
Example case: Patient given neoadjuvant docetaxel + cyclophophamide achieves a partial response after 3 cycles of Taxotere + cyclophosphamide but is u...
What fields would you treat?
Would you treat the regional nodes alone (not previously irradiated) or would you also re-treat the breast/chest wall?
Are results of BCIRG-006 trial applicable for patients with triple positive breast cancer or only for those with HER2+?
What factors would help you make your decision? (Age, genetics of lung or breast cancer, triple negative, LVSI, T2, etc?)
Are there any situations where a patient is a suitable candidate for ABPI but you still encourage standard whole breast hypofractionation?
How often will you monitor it? In the setting that patient is morbidly obese, does your strategy change?
Would you rather they delay the start of treatment so that it was >3 months from date of surgery or have a break of several weeks during XRT? Assum...
And does the fact that the breast is lactating affect radiation toxicity in anyway?
What factors would help aid your decision?
For hypofrac breast patient (such as 40 Gy in 15 fractions), what is the maximum hot spot that you will accept anywhere in the breast? 107-8%? 1...
When trying to eliminate dose heterogeneity during field in field planning for hypofractionated breast radiation with a large separation, the resultin...
Tamoxifen prophylaxis is FDA-approved, but would you extrapolate from adjuvant/metatastic data for hormone receptor positive breast cancer in post-men...
In the absence of data demonstrating a clinical benefit for one strategy versus the other, what do you do in practice?
Being that there is limited data on CNS penetration with either regimen, what would you prefer in a patient who already received whole brain RT?
The FDA recently approved neratinib based on data from the ExteNET trial; however, benefit appears modest and the risk of toxicity is not low.
If so, what regimen?
Do you have a cutoff in terms of tumor size, number of LN, Oncotype score, etc that makes you choose lower vs higher intensity chemo?
If the patient meets CALGB criteria but has EIC would you lean towards giving RT? What other factors would lead you to give whole breast RT an elderly...
There is limited data that suggests steroidal AI exemestane could be of some benefit after nonsteroidal AI failure (Lonning PE et al. J Clin Oncol 200...
Is the risk of IBRT any greater than in non mutation carriers?
Does neoadjuvant chemotherapy with complete response in the axilla alter your management preferences?
For example, would you order a PET/CT to evaluate for lymphatic or distant metastatic disease?
If a male has early stage breast cancer and would otherwise meet criteria for the CALGB or PRIME II trials, would omission of radiation be an option? ...
Does your institution do this routinely?
I.e. either for treatment of high-risk disease or intolerance/contraindication to tamoxifen. Will you continue it for the full 5 year course?
Do you prefer doing this through a "neoadjuvant" approach vs. post-operatively?
CALOR trial
How does the modest results of the APHINITY trial impact your practice?
In a patient with isolated leptomeningeal disease (no systemic disease), would you still recommend systemic therapy?
Assume good compliance with oral therapy, equivalent access to either agent, no contraindictions to either therapy, and absence of any visceral crisis...
Do you reserve this approach for only women with triple negative breast cancer or all-comers?
Given the poorer prognosis of these patients, do you approach their treatment any differently than a unilateral cancer?
Is this in addition to or mutually exclusive from oncotype/mammaprint?
Patient has hormone-refracatory disease, had high visceral burden (pulmonary mets, bone, lymph). Progressed on taxane, xeloda, gemcitabine. Now ...
Any recommendations on technique?
What would you choose if there is no response to neoadjuvant AC-T? Taxol, THP, TCHP?
Do you prefer neoadjuvant chemotherapy or proceeding directly to surgery, followed by adjuvant therapy?
e.g. how does the tumor burden on axillary dissection, sentinel biopsy only, extracapuslar extension, and the size of hte metastasis play into your de...
Assuming cytotoxic chemotherapy is given, would you still then proceed with adjuvant endocrine therapy? Would you switch agents or classes of en...
Is it still acceptable to deliver hypofractionation for what was previously a Stage I TN breast cancer, now Stage IIIA? Should RNI be considered? Or e...
(For instance, TCX4 instead of AC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemotherap...
How do you best counsel their radiation risks?
Do you prefer this approach based on the FALCON trial showing improved PFS with frontline fulvestrant?
The subquestion can be "Ex if you are offering PMRT for reasons like young age and Her2+?
Do you extrapolate the results of OPTIMIZE-2 and CALGB 70604 showing that an every 12 week dosing of zolendronic acid is noninferior to ever...
Do you attempt to have the pacemaker moved? If the patient is non-dependent, would you ever treat with the pacemaker in field?
Is there a select patient population that you use it for? Is it also being used in cancers other than breast cancer?
There are many options to choose from, including large gene panels with up to 80 genes at the same cost as BRCA 1/2 testing, while others offer j...
Is there a role for routine use of additional or alternative imaging modalities for these patients, such as tomosynthesis, MRI, or ultrasound? I...
Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...
Are there differences between palbociclib and ribociclib? What would make you choose one over the other?
E.g. someone with high grade and/or >2.5cm disease? If we use age as a cutoff in invasive disease to omit adjuvant radiation based on the...
Her2 status was not evaluated as part of the PRIME 2 or CALGB trials and luminal Her2 patients likely represent a small minority of those enrolle...
Would you recommend a mastectomy for her breast cancer in attempts to avoid RT? If the patient undergoes a lumpectomy or needs PMRT, would you a...
Example patient: 50 year old pre-menopausal woman with a familiy history of pre-menopausal BRCA1 and BRCA2 wild-type breast cancers in sister and...
For example, if a post-menopausal patient is treated in the first line setting with docetaxel, herceptin, and perjeta, would you add an aromatase...
At what point do you send these test, and in what instances do the results influence your treatment recommendations?
If not, are there certain dose constraints one considers?
If so, how do you counsel patients who are node positive with low or intermediate risk scores? How do you interpret the existing data? NCCN and ASCO g...
In a patient who underwent lumpectomy for presumed DCIS and was found to have a focus of invasive triple negative disease, would you offer chemotherap...
Is a monthly schedule x 1 year, followed by q3 months, now the the standard of care, as per the recently published OPTIMIZE-2 trial?
Is it a factor you consider, especially in borderline cases?
For instance, are you more likely to offer PMRT to a man who is node negative but with several high risk features such as high grade, LVI, high oncoty...
Is it more/less helpful if CA 15-3 is negative?
This is rarely done, but recently came up in a tumor board discussion. Which chemotherapy would you consider using, and when?
Do you ever use BID fractionation? What patient factors do you use to individualize the treatment?
If no, in what patients should axillary ultrasounds be performed?
Would your management change if the patient had extensive DCIS?
How many intercostal spaces do you include? Do you vary these parameters based on the disease characteristics?
These patients were not eligible for Z0011 and represents less than 5% of the patient population in AMAROS. Thus, can you apply these two trials to ju...
Would you send the patient to a surgeon for consideration of a mastectomy? Would you then consider post mastectomy radiation when the risk of re...
The CALOR study showed a benefit of adjuvant chemotherapy for local recurrence but the regimens given were "physicians choice".
How do you counsel them on risk in the curative setting? Do you approach treatment in the metastatic setting any different than patients with &g...
What are indications for adjuvant radiation for a early stage well differentiated adenosquamous carcinoma of the breast? What is the best radiation th...
Does switching AIs help? If so, is there a role for switching from a steroidal AI to a non-steroidal AI or vice versa? Are there other adj...
Based on results from PALOMA1 and recently reported MONALEESA2, do you use a CDK4/6 inhibitor as initial therapy? In what circumstances would yo...
What factors in particular guide your recommendation of PMRT for invasive lobular carcinoma?
Would your management change if including the drain sites requiree treating more lung or adding separate electron fields?
Does your recommendation change depending on the agents they received?
What factors do you consider when offering PMRT? Would you change your dose/fx and/or field size?
The results of the 70 gene panel Mammaprint in combination with Adjuvant! Online were published in NEJM recently. How will you incorporate this data i...
Do you ever consider de-escalating or stopping therapy in this situation? What is your approach to this conversation?
The MA17R trial only included "postmenopausal women" so how do you make a decision for men and pre-menopausal women.
What if the patient has a BRCA1/2 mutation?
Women with cN1 disease at diagnosis who are ypN0 after neoadjuvant chemo can be randomized on NSABP B-51, but not those with cN0 disease and treatment...
What about in cases of a tunneled lumpectomy cavity using a circumareolar incision?
The patient has refused termination of pregnancy.
Do you always stick with a conventional fracionation, or in some cases, are you comfortable hypofractionating? Do you ever use a wait and see approach...
Would you recommend re-excision of a positive margin containing only pleomorphic LCIS prior to radiation for BCS? Does the presence of ...
What about patients with bone-only metastases?
Do you use cytotoxic chemotherapy as first line or hormonally-targeted therapy such as letrozole + palbociclib?
Are there any data to support whole breast RT, SBRT, or cryoablation?
Based on the CALOR trial (http://www.ncbi.nlm.nih.gov/pubmed/24439313), adjuvant chemotherapy should be considered, but what regimen is preferred?&nbs...
What factors do you consider when adding post-lumpectomy radiation therapy for treatment of an intracystic papillary carcinoma?
Randomized trials in the 1980s demonstrated equivalent survival and disease control outcomes for lumpectomy + RT vs mastectomy, but several recent pop...
Do you have a formalized approach, or is it a case by case decision? Do you use bolus differently for a TRAM, tissue expanders, implants, etc?
Do you prioritize certain dosimetric parameters over others (e.g., considering the Darby report, mean dose to the heart vs. mean LAD dose?)
In a patient who recently completed NAC, TM/LND and PMRT for a hormone positive locally advanced breast cancer and is then found to have a contralater...
The recently published MA.17R trial showed a DFS benefit for extending AI therapy to 10 years in post-menopausal women.
Assuming the patient is a candidate for either of these treatments?
A recent publication of the TEXT and SOFT trials http://www.ncbi.nlm.nih.gov/pubmed/27044936 showed an improvement in breast cancer-fre...
If so, what fields should be used?
Are there any tips on how to best use this technique?
If there is a signifcant amount of breast tissue contacting the couch in the prone position, are there strategies that can be used to mitigate po...
Comparison of prone versus supine positioning showed that 85% of patients with left sided breast cancer benefit more from the prone versus supine posi...
Since we know that both the "Canadian" fractionation and partial breast irradiation work as treatment for early stage breast cancer in the same patien...
The Hughes study looked at women > 70 years of age. In light of the PRIME II results, can women aged 65 - 70 avoid RT or is longer follow up needed...
Would you change your management based on receptor status (ER/PR+/HER2 neg vs triple neg) or menopausal status (pre vs post menopausal)? Would you tre...
Would this be considered acceptable in an older woman with high grade disease?
Can it be avoided in patients with a microscopically positive lymph node?
Dose in many studies were often prescribed to a point rather than a volume and with 3D planning, we may be upping the breast dose. The D2eq dose...
If so, how do you target this boost?
Does the recent Danish Breast Cancer Group IMN study (JCO 11/23/15), showing a survival benefit to IM irradiation in patients with early stage no...
Do you routinely do Oncotype DX testing in these patients?
If not, do you have any experience with acceptable late toxicity and cosmesis with whole breast radiation in these patients?
Can the IMNs ever be spared, or would you consider it mandatory for all inflammatory breast cancers?
E.g. breast? I have found no literature on skin tolerance acutely or chronically.
Are there any clinical or pathologic factors that lean you towards or away from giving trastuzumab?
Our Radiation Safety officer reports a higher radiation dose to the patient from the two scans vs the PET.
Do you put more weight on specific CVDs such as scleroderma as contraindications for any RT?
Is your decision influenced by factors such as the location of the intramammary nodes and/or the mapping of sentinel nodes to the axilla?
There seem to be good prospective studies (Australian study and Canadian study) which debunk the thought that deodorants/antiperspirants increase skin...
If the patient has no pathologic risk factors that would ordinarily necessitate PMRT, do you omit it? Does triple negative subtype affect your decisio...
Would the risk of radiation-induced second malignancy outweigh the benefit of locoregional control for a young patient with high grade DCIS?
Do you have any concern for increased toxicity when you treat a patient with radiation therapy who has an autoimmune disorder? (hypofractiationation v...
With conventional RT, the dose to the brachial plexus should be no more than 50-55Gy max. One exception to this is the addition of PAB in conventional...
Do you look at pretreatment breast MRI or post surgical assessment of the tumor bed/treatment effect? How would you resolve discrepancies betwee...
Would triple negative disease effect your decision?
In a patient with a T1 breast cancer who underwent mastectomy and ALND and recurred in the axilla a year later, would you offer RT to the chest wall a...
i.e. are there any situations where you may recommend against using hypofractionation for a patient with left sided breast cancer such as dose constra...
What if the pre-chemo FNA of the suspicious node is negative?
Borderline cases such as patients that received NAC with a complete response or N1 disease with 1-3 positive nodes make me think frequently about this...
Would extensive residual DCIS (>5cm), hormone receptor negativity, Her2+ status, or age < 40 effect your decision?
Are all bisphosphonates equal in its efficacy? What dose?
Is there any literature supporting that a gentle fractionation/bid regimen (i.e., 1.5Gy bid x 30 = 45Gy) is safer than a standard fractionation ...
Does the axilla have to be addressed surgically or with RT, given that the AMAROS trial eligibility criteria were amended to address sentinel lymph no...
Or, as this is presumed metastatic disease, would you recommend systemic treatment and defer RT?
If so, how do you decide which patients to treat with breath hold vs. free breathing? Do you routinely perform 4D CTs?
A 40 year old patient receiving post-op RT for breast cancer asked me if there is any risk for her becoming pregnant after completing RT. Eric H...
In a patient with Stage IE DLBCL, is your treatment volume postchemo ISRT or whole breast? Would you consolidate if a lumpectomy was performed prior t...
Is it a function of the type of reconstruction contemplated?
The 2013 ASCO guidelines and current NCCN guidelines recommend yearly mammograms but our radiologists are still recommending mammograms every 6 m...
If the patient has negative axillary nodes and no other signs of high risk disease other then a local chest wall failure, do I still need to treat the...
They used to be given concomitantly now they are done sequentially. I can only find conflicting data to justify this trend.
If so, do you do this routinely or only in certain circumstances? Is there data to support routine mammogram before breast radiotherapy?
In a case-control study by Darby et al in the New England Journal of Medicine, patients treated for breast cancer with radiation were found to have an...
Or for that matter, offer PMRT on the basis of a patient having triple negative disease?
I'm not sure how to interpret the results of the study published in JNCI earlier this year.
My institution is considering a major investment/purchase of this technology to complement our existing array of breast radiotherapy options.
In other words, have the results of the MA.20 and EORTC trials changed your practice?
Has the recent 12-year ECOG update for surgical excision of DCIS without radiation therapy changed your practice management?
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