Oncology Self-Assessment: Breast Cancer and Melanoma

Mar 21, 2023

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 2022 ASCO-SEP Digital Subscription, which includes the digital book, access to education courses and virtual meeting-related content, plus over 1,000 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 2022-2023 cycle.
Correct answers are listed at the bottom of the page.

Question 1: Breast Cancer

Three years ago, a 58-year-old woman was treated with lumpectomy, chemotherapy, and radiation for stage II estrogen receptor–positive, progesterone receptor–positive, HER2–negative breast cancer. She stopped taking hormonal therapy after one year. She now presents with a worsening lump around the surgical site on her right breast. A biopsy reveals invasive ductal carcinoma that is estrogen receptor–positive, progesterone receptor–positive, HER2–negative. The lump is 2 x 3 cm in size; the patient has an Eastern Cooperative Oncology Group (ECOG) performance status of 0 and no contraindications to surgery.
Which of the following is the most appropriate next step?
  1. Mastectomy
  2. Lumpectomy
  3. Hormonal therapy
  4. Radiation therapy

Question 2: Melanoma

A 70-year-old woman with no significant medical history presents with a 3-month history of a firm, pink skin nodule on the right lower leg, which has been slowly progressing. There is a palpable lymph node in the right inguinal region that is firm, fixed, and non-tender, measuring approximately 2 cm in diameter. She has no B symptoms. A punch biopsy of the skin lesion reveals CK20-positive, TTF-1-negative, infiltrative, malignant appearing cells, with brisk tumor-infiltrating lymphocytes. A PET/CT scan reveals a 2-cm right inguinal lymph node with fluorodeoxyglucose (FDG) uptake and maximum standardized uptake value (SUV) of 10, as well as multiple FDG-avid liver and lung lesions ranging between 1 and 3 cm in diameter.
Which of the following is the most appropriate next step?
  1. Cisplatin
  2. Cemiplimab-rwlc
  3. Pembrolizumab
  4. Topotecan

Question 1 Rationale and Reference

Correct answer: A. Mastectomy
Rationale: After lumpectomy and radiation therapy, mastectomy is the ideal surgical option. Further radiation cannot be given. Hormonal therapy would only have a role after surgery. The CALOR trial showed some benefit in adjuvant chemotherapy, but not for estrogen receptor–positive disease. Upfront surgery is the mainstay of treatment for operable locally recurrent disease. Other therapy modalities can be considered after surgical resection.

Question 2 Rationale and Reference

Correct answer: C. Pembrolizumab
Rationale: Immunotherapy with pembrolizumab was approved in 2019 by the FDA for the treatment of advanced Merkel cell skin cancer based on an overall response rate of 56% (complete response of 24% and partial response of 32%) in clinical trial KEYNOTE-017 which was nonrandomized, open-label. Avelumab was approved in 2017 as well. Chemotherapy can lead to high response rates but has minimal impact on survival due to the short progression-free survival associated with chemotherapy. Cemiplimab-rwlc is approved for advanced squamous cell skin cancer.
  • Nghiem P, Bhatia S, Lipson EJ, et al. Durable tumor regression and overall survival in patients with advanced Merkel cell carcinoma receiving pembrolizumab as first-line therapy. J Clin Oncol. 2019;37(9):693-702. DOI: https://doi.org/10.1200/JCO.18.01896 
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