Feb 09, 2022
Test your knowledge of breast cancer and gastrointestinal cancers with two multiple-choice questions from the ASCO Self-Evaluation Program (ASCO-SEP) on ASCO Education.
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. Questions are developed by a group of oncology experts in multiple tumor topic areas. The self-assessment questions are aligned with the American Board of Internal Medicine (ABIM)’s Medical Oncology blueprints and ASCO’s Medical Oncology In-Training Exam (ITE) blueprints.
Review the Education Essentials for Oncology Fellows (EEOF) package, which includes the ASCO Self-Evaluation Program (ASCO-SEP), hosted on ASCO Education for more online education.
Correct answers are listed at the bottom of the page.
Question 1: Breast Cancer
A 56-year-old postmenopausal woman noticed a lump in her left breast, prompting further evaluation. A diagnostic mammogram noted a spiculated mass in the upper outer quadrant of the left breast, along with abnormal axillary lymph nodes. Ultrasonogram noted a hypoechoic mass measuring 1.8 cm and three suspicious lymph nodes in the axilla. Ultrasonography-guided core needle biopsy of both the mass and lymph nodes noted grade 3 invasive ductal carcinoma, with estrogen receptor-, progesterone receptor-, and HER2-negative status. She received dose-dense doxorubicin and cyclophosphamide for four cycles, followed by weekly paclitaxel for 12 cycles. She experienced a good response clinically; neither palpable mass in the left breast nor lymph nodes in the axilla were detected. After lumpectomy, residual tumor measured 0.8 cm, and sentinel lymph node biopsy noted no malignant cells.
Which of the following is the most appropriate next step?
- Adjuvant radiation therapy
- Adjuvant capecitabine
- Adjuvant radiation therapy and adjuvant capecitabine
Question 2: Gastrointestinal Cancer
A previously healthy 63-year-old woman initially presented to her primary care physician with iron-deficiency anemia. Work-up revealed an ascending colon mass that was biopsied and confirmed to be invasive adenocarcinoma. She underwent a right hemicolectomy. Final pathology noted a 3-cm adenocarcinoma, with invasion through the muscularis propria and one of 18 lymph nodes involved; pathologic staging was pT3pN1. Resection margins were tumor free. The tumor showed proficient mismatch repair proteins. She has recovered well and presents to your clinic to discuss adjuvant therapy.
What is the most appropriate next step in management?
- Observation with surveillance imaging in 6 months
- Adjuvant oxaliplatin, leucovorin, and fluorouracil (FOLFOX) for 6 months
- Adjuvant capecitabine and oxaliplatin (CAPOX) for 3 months
- Adjuvant capecitabine for 6 months
Question 1 Rationale and Reference
Correct answer: D. Adjuvant radiation therapy and adjuvant capecitabine
Rationale: The CREATE-X trial showed improved disease-free and overall survival when adding adjuvant capecitabine therapy after standard neoadjuvant chemotherapy containing anthracycline, taxanes, or both in patients with HER2-negative breast cancer who had residual invasive disease on pathologic testing.
- Masuda N, Lee SJ, Ohtani S, et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med. 2017;376:2147-59. DOI: https://doi.org/10.1056/NEJMoa1612645.
Question 2 Rationale and References
Correct answer: C. Adjuvant capecitabine and oxaliplatin (CAPOX) for 3 months
Rationale: For patients with resected stage III colon cancer, adjuvant chemotherapy is indicated. There is disease-free and overall survival benefit with the addition of oxaliplatin to fluoropyrimidine-based adjuvant therapy, particularly in patients younger than 70 years. The IDEA collaboration demonstrated that 3 months of adjuvant CAPOX was noninferior to 6 months of adjuvant FOLFOX with decreased toxicity, particularly decreased neuropathy.
- Grothey A, Sobrero AF, Shields AF, et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378:1177-88. DOI: https://www.doi.org/10.1056/NEJMoa1713709.
- André T, Boni C, Navarro M, et al. Improved overall survival with oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment in stage II or III colon cancer in the MOSAIC trial. J Clin Oncol. 2009;27:3109-16. DOI: https://doi.org/10.1200/JCO.2008.20.6771. Epub 2009 May 18.