Skipping the Endocrine Queue

When do you leapfrog another aromatase inhibitor and go for T-DXd? Triggers include  6-month PFS on prior lines, bilirubin/LFT creep from liver mets, ESR1 erosion to 20 %, and any visceral crisis that won’t wait two more “endocrine” months. In those scenarios the panel declares the tumor “endocrine-refractory” and reaches for T-DXd decisively.