Sample responses from Dr. Sager.

Dear Linda,

Thank you for reaching out. You mentioned feeling unsure about why your breast cancer treatment included surgery and radiation but no chemotherapy. It’s understandable to want reassurance that nothing important has been missed.

Based on the information you shared, your oncologist’s recommendation appears well supported. Your cancer was hormone-receptor positive and HER2-negative, with no cancer found in the lymph nodes. Your Oncotype DX test—which helps estimate whether chemotherapy would help—had a score of 12. For women over 50 with these findings, research supports hormone-blocking treatment without adding chemotherapy. Not receiving chemotherapy does not necessarily mean receiving less effective care.

The letrozole you are taking is an important part of that plan. It lowers estrogen levels to help reduce the chance of the cancer returning.

The stiffness in your hands and knees deserves attention, too. Letrozole can cause joint pain, although your care team should check whether something else is contributing. There may be ways to relieve the symptoms, and sometimes changing to another hormone-blocking medicine helps. Please speak with your oncologist before stopping or changing treatment.

A useful question to bring to your next appointment is: “Could the stiffness be related to letrozole, and what could we try to make treatment more tolerable?” Let them know which activities have become difficult and whether the discomfort is affecting your sleep.

You mentioned considering a second opinion. We can help identify a breast cancer specialist near you to review the plan—not because we have identified a problem with it, but because you would like another expert’s perspective, and we agree it is a reasonable request. Since you live in Texas, please let us know if you’d be willing to travel to MD Anderson, or are restricted to a shorter drive.

When is your next oncology appointment? Please let me know, along with how much the stiffness is affecting your daily life. Is it worse in the morning or evening, and have you tried anything (ibuprofen [Advil] or topical diclofenac [Voltaren])?  We’re here to help you work through these questions and would be glad to hear how the appointment goes.

Dear Sarah,

Thank you for reaching out and sharing what has been happening. I’m sorry your latest scan showed that the pancreatic cancer is growing despite chemotherapy. I’m glad you contacted us as you consider what comes next.

One detail in your tumor testing provides a clue for personalized cancer treatment: a gene change called KRAS G12D. Instead of only looking for generic (or unselected) pancreatic cancer trials, we can look for studies testing treatments specifically designed for this change. There are more than 30 KRAS drugs being tested with about half already showing promising data, and 2 that have already been FDA-approved.

One study worth discussing evaluates RMC-9805, a pill designed to block the altered KRAS G12D protein. It includes people with advanced pancreatic cancer with this mutation who have already received standard treatment. This is an early study, and initial results have been reported, but it is not yet clear whether RMC-9805 would help in your case. However, because it is specific for the G12D mutation, we believe it could be better than a medicine that covers all KRAS mutations or cause fewer side effects like rash. 

Since you live near Baltimore, Johns Hopkins is a nearby center to ask about this trial. Dr. Nilo Azad is on Johns Hopkins' early-phase trials team, though the study listing does not confirm that she leads it locally. You can reach the program's referral nurse at 410-502-5140 and ask about the RMC-9805 study.

Your mutation alone does not establish eligibility—the team would need to review your treatment history and overall health. They would also need to confirm whether a slot is available. When you see them to learn more about the trial, ask how often you would need to visit so you can consider the practical side, too.

Your oncologist likely has standard treatment options; a second opinion with Dr. Azad could help you compare those with trial options, such as the RMC-9805 study.

When is your next oncology appointment? Please let me know, along with any questions or concerns you would like help working through, especially if you have trouble reaching Dr. Azad