In a patient with metastatic HR+/HER2- breast cancer who progressed on adjuvant hormonal therapy, do you start fulvestrant + CDK4/6i or do you wait for NGS testing to determine eligibility for targeted agents such as elacestrant or PIK3CA inhibitors?   

I wanted to edit my prior response. There has been a rapid communication from ASCO on this topic: "Endocrine and Targeted Therapy for Hormone Receptor–Positive, Human Epidermal Growth Factor Receptor 2–Negative Metastatic Breast Cancer—Capivasertib-Fulvestrant: ASCO Rapid Recommend...

I typically order upfront NGS testing at the time of HR+/HER2- metastatic breast cancer diagnosis with the idea that I will have the PIK3CA mutation information already available at the time of cancer progression to streamline decision-making regarding the next line of treatment. I also repeat the t...