I think the jury is out on the decision to give combination therapy or single-agent therapy first line. Oncologists have to come to their own conclusions by assessing whether patients are low, intermediate, or high risk.

— Peter Schmid, MD, PhD

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Several practice-changing studies have shown that adding a CDK4/6 inhibitor to an aromatase inhibitor improves survival in hormone receptor–positive advanced breast cancer, and those results should also be considered, said formal discussant Peter Schmid, MD, PhD, of Bart’s Cancer Institute, Queen Mary University, London, UK. In that setting, the question is which patients can be treated with hormonal therapy alone and which ones will require combination therapy with a CDK4/6 inhibitor, as well as what is the role of fulvestrant.

“I think the jury is out on the decision to give combination therapy or single-agent therapy first line,” Dr. Schmid said. “Oncologists have to come to their own conclusions by assessing whether patients are low, intermediate, or high risk. In my view, there remains a role for single-agent endocrine therapy in low-risk patients. For intermediate-risk patients, endocrine therapy plus a CDK4/6 inhibitor is a reasonable approach. The high-risk group is the most important and most neglected group. Too many of us still give chemotherapy upfront—about 70% of patients. The advantage of the CDK4/6 combination is that we can offer endocrine therapy to more patients.” ■

Disclosure: Dr. Schmid reported no potential conflicts of interest.