Jul 14, 2022
ASCO seeks to advance the education of all oncology professionals and ultimately facilitate and support enhanced patient care. The ASCO Oncology Self-Assessment Series on ASCO Connection consists of free case-based multiple-choice practice questions, educational links, and answer rationales from ASCO-SEP.
Learn more about ASCO’s Educational products, such as the new 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 900 practice questions in the Question Bank. Oncology trainees and Training Program Directors can visit Education Essentials for Oncology Fellows (EEOF) to learn more and register for the new 2022-23 cycle.
Correct answers are listed at the bottom of the page.
Question 1: Breast Cancer
A 67-year-old woman presents to your clinic following a screen-detected diagnosis of right breast cancer. She has undergone a partial mastectomy and a sentinel lymph node biopsy. Her pathology reveals a 1.5-cm invasive ductal carcinoma, grade 2, that is estrogen receptor–positive, progesterone receptor–positive, and HER2-positive by immunohistochemistry. Margins are negative and no sentinel lymph nodes are involved. Her Oncotype recurrence score was 15. Bone density evaluation is within normal limits.
Which of the following would be the preferred adjuvant treatment approach?
- Hypofractionated whole breast irradiation with tamoxifen
- Conventional whole breast irradiation with tamoxifen
- Hypofractionated whole breast irradiation with aromatase inhibitor
- Conventional whole breast irradiation with aromatase inhibitor
Question 2: Head and Neck Cancers
Fourteen months ago, a 55-year-old man presented to an otolaryngologist with an enlarged left neck mass. Biopsy at the time showed squamous cell carcinoma. Direct laryngoscopy showed a remaining vocal cord tumor with no vocal cord fixation. The patient missed his follow-up appointment, and he continued to consume a twelve-pack of beer and a pack of cigarettes daily. He now presents with a much larger mass and hoarseness. Direct laryngoscopy shows a 2-cm left vocal cord mass limited to the larynx with vocal cord fixation. A swallowing study shows mild penetration of thin liquids, but overall his larynx is functional. A CT scan shows the above mass with bulky left-sided lymphadenopathy encasing the carotid artery. One node measures 6.5 cm. There is no thyroid cartilage invasion. A radiation oncologist determined it was not in the patient's best interest to pursue treatment at this time, owing to the bulk of the cervical lymphadenopathy.
Which of the following is the most appropriate next step?
- Refer for supportive care
- Refer for debulking surgery
- Cisplatin, followed by sequential radiation therapy
- Cisplatin, docetaxel, and fluorouracil (TPF), followed by concurrent chemoradiation
Question 1 Rationale and References
Correct answer: C. Hypofractionated whole breast irradiation with aromatase inhibitor
Rationale: Hypofractionated whole breast irradiation has had a slow uptake despite evidence of safety, efficacy, good cosmesis, and superior cost and convenience in comparison to conventional whole breast irradiation. Hypofractionated whole breast irradiation has been included in the American Society for Radiation Oncology (ASTRO) Choosing Wisely campaign, in addition to the referenced guidelines. In postmenopausal women, aromatase inhibitors are superior to tamoxifen in reducing recurrence and should be the preferred initial endocrine therapy.
References
- Smith BD, Bellon JR, Blitzblau R, et al. Radiation therapy for the whole breast: executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Pract Radiat Oncol. 2018;8(3):145-52. DOI: https://doi.org/10.1016/j.prro.2018.01.012
- NCCN. National Comprehensive Cancer Network Guidelines in Oncology. Breast Cancer. Available at: https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf
Question 2 Rationale and References
Correct answer: D. Cisplatin, docetaxel, and fluorouracil (TPF), followed by concurrent chemoradiation
Rationale: Supportive care is not appropriate, as this patient has treatment options with curative potential, despite his stage IVb disease. Debulking surgery is neither standard of care nor curative and would require extensive reconstruction, delaying curative therapy. Chemotherapy followed by radiation (sequential treatment) is not standard of care, nor is cisplatin alone an adequate induction therapy. Induction TPF followed by chemoradiation is a validated treatment modality. This approach confers superior locoregional control and overall survival when compared to radiation alone, as well as shorter duration of therapy when compared to chemotherapy with sequential radiation, as supported by the Intergroup 91-11 trial. A meta-analysis of five randomized controlled trials demonstrated that induction TPF reduced risk of death, as well as disease progression, locoregional failure, and distant failure, when compared to cisplatin and fluorouracil doublet regimen.
References
- Lefebvre JL, Pointreau Y, Rolland F, et al. Induction chemotherapy followed by either chemoradiotherapy or bioradiotherapy for larynx preservation: the TREMPLIN randomized phase II study [published correction appears in J Clin Oncol. 2013 May 1;31(13):1702]. J Clin Oncol. 2013;31(7):853-59. DOI: https://doi.org/10.1200/JCO.2012.42.3988
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Head and Neck Cancers. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
- Blanchard P, Bourhis J, Lacas B, et al. Taxane-cisplatin-fluorouracil as induction chemotherapy in locally advanced head and neck cancers: an individual patient data meta-analysis of the meta-analysis of chemotherapy in head and neck cancer group. J Clin Oncol. 2013;31(23):2854-60. DOI: https://doi.org/10.1200/JCO.2012.47.7802