Breast Cancer, Non-metastatic
Questions discussed in this category
Are there any subgroups that would still benefit from RNI?
Would you offer adjuvant Pembrolizumab combined with Capecitabine?
Does the low ER+ or metaplastic histology affect your recommendations?
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...
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?
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 be more inclined to use it if a patient had early discontinuation of pembrolizumab due to IRAE?
Oncotype score in this case was 14.
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.
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...
As immune checkpoint inhibitors have expanded into the neoadjuvant breast cancer setting, severe and unexpected autoimmune toxicities may cause delays...
What factors would influence your decision?
Since HR low-positive, HER2 neg tumors behave aggressively similar to TNBC, does the degree of HR positivity factor into your decision-making?
Does the type of breast cancer factor into your decision making?
Would you no longer trust the prognostic value of Mammaprint knowing the poor response to endocrine therapy?
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...
Would you still treat with neoadjuvant KEYNOTE-522?
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?
Does the presence of other cardiac risk factors change your recommendation?
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?
Given OlympiA trial with olaparib benefit for gBRCA+ patients?What are barriers that you foresee? In your practice who performs mutation testing and w...
Would you offer adjuvant radiation therapy if pCR is confirmed?
Group 3 being ratio < 2, copy # >6, and IHC 2+
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...
How does it affect your calculation of risk stratification?
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?
If so, in what situations?
Both sets of CT scans pre and post- chemoimmunotherapy show no evidence of distant mets.
For example, a patient has had multiple dose reductions for neutropenia and required an admission for infection while on palbociclib. Would you switch...
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 consider OFS this far out from diagnosis and treatment in a young patient with high grade IDC was treated during pregnancy with neoadjuvant ...
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...
What type of adjuvant chemotherapy would you offer? Would clinically positive lymph nodes or residual disease at the time of surgery change your decis...
Would you consider doing this in patients with adverse features such as grade 3 or PR negative status?
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
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?
Is deferring chemotherapy based on low oncotype acceptable in setting of recurrence?
Would you recommend using a different AI, Tam...
Would you recommend using chemotherapy based on RxPonder regardless of Oncotype score in a premenopausal patient? Or would you hold chemotherapy since...
With the recent announcement that the phase 3 MonarchE trial met its primary endpoint.
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...
Assuming the patient had no prior radiation and has no evidence of metastatic disease, would you start with adjuvant radiotherapy or adjuvant systemic...
She achieved PCR with NAC with TCHP and is now on adjuvant HP.
Tumor 3 cm, grade 2 with Ki-67 25%
How do you reconcile these findings with the ABC trials?
(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?
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?
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.
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.
Fertility preservation already complete with embryo cryopreservation
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...
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.
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)...
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...
The prior recommendations were between 6-12 months, but also were based on chemotherapy after surgery.
In a woman with high-grade, clinically node positive invasive ductal carcinoma who receives neoadjuvant chemotherapy and breast conserving surgery, wo...
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?
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?
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?
MonarchE shows statistically significant improvement in IDFS and DRFS, but the magnitude of absolute benefit is modest (3-year IDFS and DRFS rates = 5...
Some payors prefer leuprolide acetate injectable suspension (eligard) for ovarian suppression. This is not the preparation that was used in SOFT/Text ...
Assuming chemotherapy is indicated because of the Oncotype score.
Majority of patients on MonarchE received neoadjuvant/adjuvant chemo.
Does the availability of abemaciclib impact your decision to offer chemo ...
Patient had estradiol level checked by her gynecologist due to recent irregular bleeding. Estradiol level was markedly elevated on initial testing (90...
Do you look into their stage/risk to decide? Since patients can experience bone loss after stopping denosumab, how do you plan to discontinue?
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...
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?
- 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...
Endocrine therapy is usually not indicated for DCIS s/p bilateral mastectomy, but would the fact that residual tissue (nipple-sparing) alter your deci...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
...
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 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...
OlympiA trial did not include her2+ breast cancer.
The OncotypeDx score was 51 in this scenario.
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...
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...
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?
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? &...
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...
How much of the benefit of adjuvant chemotherapy do you expect to be due to ovarian function suppression due to the chemotherapy?
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?
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%
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.
How would you proceed given that cT1c didn't meet the study criteria?
Currently on C2 of doxorubicin/cylophosphomide/pembro. Would you expedite surgery?
Would you continue pembrolizumab? Would you introduce olaparib? If using both, how would you sequence?
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...
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%
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
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...
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+/...
Are there factors to explain why MonarchE was a positive study and PALLAS was not?
High-risk criteria meaning >4 positive nodes and Ki67 >20%
Given arguments exist between the FDA and ASCO, where do you stand?
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
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...
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.
This situation can feel uncomfortable. Would this feel safer if patient is s/p mastectomy and had TNBC?
Largest invasive focus is 0.4mm
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...
If blood counts are sustained, do you continue or delay?
Should patients with moderate penetrance pathogenic variants be managed similar to BRCA patients and consider risk reducing contralateral mastectomy?&...
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?
ER <1%; PR 45%, Her2 negative by IHC and FISH. Grade 3, Ki67: 80%.
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 ...
Do you have a specific age cutoff?
Presuming that work-up for cardioembolic sources is negative, how would you proceed?
How would you approach a patient who is intolerant of AI and develops thrombosis while on SERM?
No sentinel lymph node biopsy was performed
How would the use of Oncotype guide your management in the neoadjuvant setting?
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...
In patients who have completed all adjuvant therapy. Similar test to what is available for stage 2 and 3 colon cancer patients by Natera.
How would your management differ in pre- and post-menopausal females?
Would your approach differ if patient is premenopausal or postmenopausal?
<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.)...
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...
The GeparSixto, CALGB 40603, and more recently Prospero support doing it; however, it is not currently endorsed by NCCN and the latter Prospero s...
Masuda et al., NEJM 2017
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%)
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...
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.&...
Would your decision for anthracycline change if the patient were elderly?
Would you send Oncotype during chemotherapy if not sent already? Would you stop adjuvant chemotherapy if a prior Oncotype was 25 or less?
Would you send an Oncotype RS to determine the role of adjuvant chemotherapy and/or endocrine therapy?
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....
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?
Does tumor size impact your recommendation? High grade? Young patient age?
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?
Would you consider ALND and /or XRT to axilla?
She had already completed ddAC and two cycles of paclitaxel before the reaction.
Recent EBCTCG meta-analysis published in Lancet 4/2023. https://doi.org/10.1016/S0140-6736(23)00285-4
Pre-menopausal women make progesterone and their menses are typically lighter on tamoxifen because it's a mild endometrial ER stimulant blocking their...
Would you test initial core biopsy (prior to neoadjuvant anastrozole) or surgical specimen? Any preference for Oncotype vs. Mammaprint?
How do you counsel regarding uterine sarcoma risk?
What timeframe would you suggest to stop breastfeeding? From affected breast or both breasts?
She had had 4 prior biopsies. Would the fact that she received 2 months of neoadjuvant tamoxifen due to COVID change your approach?
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. ...
Out of curiosity, I did tumor testing, and she does not have an activating ESR1 mutation.
< 4 lymph nodes involved, initial diagnosis was 11 years ago when she was treated with mastectomy and adjuvant tamoxifen for 5 years.
If the cancer was also HER2+, would that influence your decision?
Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...
She has received 4 cycles of AC with no clinical response and is now pending completion with Taxol.
Would your choice vary based on the patient's gender?
Would you consider delaying chemotherapy and proceeding only with endocrine for now?
IHC: ER 70%; PR 70%
OncotypeDx: ER - Negative; PR - Positive
Do you proceed with Paclitaxel or go to surgery instead?
Pre-treatment estradiol: <5
Estradiol after 1 yr: 35
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...
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...
Are there clinical scenarios in which 5 years of tamoxifen alone remains sufficient?
Would you offer AI + OFS or tamoxifen to a woman with a grade 3 T2N0 tumor and OncoType of 15?
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?
Margins were negative and there was no evidence of LCIS or lobular component in the lumpectomy specimen. Role for possible mastectomy?
More generally, do absorption issues effect the efficacy of tamoxifen and/or aromatase inhibitors?
Role of neoadjuvant TC vs. anthracycline based regimen?
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...
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 so, what is the ideal imaging?
If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?
High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.
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?
Papers discussed in this category
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Cancer, 2010-11-15
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Annals of oncology : official journal of the European Society for Medical Oncology, 2019-04-01
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Annals of oncology : official journal of the European Society for Medical Oncology, 2012-06
Br J Cancer, 2019 Jan 17
American journal of clinical oncology, 2016-10
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