Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would you use as adjuvant endocrine therapy for a patient who developed an invasive, hormone receptor positive breast cancer while on raloxifene for almost a decade prior?
In this situation I would use an aromatase inhibitor if possible. One would not expect an ESR1 activating mutation to be readily detected after treatment with a SERM, since estrogen deprivation rather than receptor blockade enriches for ESR1 mutant clones.
In a patient with inflammatory triple-positive breast cancer who has a pCR to neoadjuvant chemotherapy, but has an incidentally found focus of intermediate-grade ER+/PR+/HER2- ILC in the mastectomy specimen, how would this impact your adjuvant radiation recommendations?
This finding would not have any impact on my recommendations, since her management needs to be guided by the inflammatory breast cancer. That means chest wall plus nodal irradiation tailored to the findings of axillary surgery. There are no data on whether we can decrease the dose in patients with a...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
In the setting of COVID-19, would you perform a SLNB for a patient incidentally found to have microinvasive ER+ ILC in contralateral prophylactic mastectomy following neoadjuvant chemotherapy for a locally advanced triple positive breast cancer?
I would not recommend SLN biopsy, independent of COVID-19. This patient's prognosis is overwhelmingly dependent on the locally advanced triple negative breast cancer, not the microinvasive ER positive breast cancer. Acknowledging that the ER positive cancer may have been larger than microinvasive be...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
For patients with metastatic cancer on a systemic therapy regimen that includes bevacizumab, are you comfortable treating brain metastases (SRS or WBRT) without holding bevacizumab?
Multiple prospective trials have demonstrated the safety of combined bevacizumab and radiosurgery (from both recurrent GBM and brain mets) with some data to actually demonstrate a protective effect against radionecrosis. No significantly increased synergistic risk of intracranial bleed has been obse...
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...