Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In general, how do you manage patients with early-stage endometrioid endometrial cancer who have concomitant POLE and TP53 mutations?
Based on published outcome data, double mutation is uncommon, and the outcome is driven by the better of the two mutations. So in the above situations, POLE type and not TP53 type will drive outcome and treatment decisions. That’s why in molecular-based decisions, it is important that the POLE type ...
How would you approach the treatment of low grade, stage IA, triple negative apocrine adenocarcinoma of the breast in a female patient in her 70s?
I would not treat this the way I would a typical triple-negative breast cancer, since the risk of distant recurrence from occult metastatic disease is low. Assuming she had breast-conserving surgery, radiation, favoring partial breast, is reasonable. In terms of systemic therapy, if the cancer in th...
Do you consider estrogen patches in treatment of prostate cancer?
Oral estrogenic formulation (such as DES) was historically used for androgen suppression in prostate cancer patients. This was based on the principle that estrogen decreased serum testosterone levels by suppressing luteinizing hormone production through a negative feedback loop on the hypothalamus a...
Which patients, if any, do you offer transdermal estradiol as a method of ADT instead of LHRH agonists?
My default form of ADT remains a GnRH agonist or antagonist but estradiol transdermal patches are clearly effective and safe as an alternative option for men who either 1) have significant loss of bone density/osteoporosis, 2) have significant hot flashes with traditional ADT and wish to try an alte...
What initial systemic approach will you recommend for metastatic pMMR HER2-positive esophageal/GEJ/gastric adenocarcinoma with PDL1 of 0?
FOLFOX-trastuzumab-pembrolizumab is consistent with the 2023 Immunotherapy and Targeted Therapy for Advanced Gastroesophageal Cancer: ASCO Guideline (Shah et al., PMID 36603169). In KEYNOTE-811, a response benefit was shown by adding pembrolizumab to trastuzumab plus chemotherapy. In this trial, 13%...
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
In a patient with unresectable HCC who developed immune-related colitis with the first dose of tremelimumab/durvalumab, would you consider continuing durvalumab alone after resolution of the colitis with steroid treatment?
I haven’t seen too many TREMI/DURVA colitis cases, but basing experience off of BOT/BAL, which is notorious for the CTLA-4 inhibitor-related BOT-colitis, as well as some patients who have had IPI/NIVO colitis, or any grade ≥3 event in the combination setting, it’d be reasonable to continue the PD1/P...
Would you offer adjuvant therapy to a patient with a high-grade mucinous appendiceal neoplasm that is pT3 pN0 M0, >12 lymph nodes removed with ileocecectomy?
I would.
How long would you continue atezolizumab/bevacizumab in a patient with HCC who is having a prolonged response with stable disease?
Similar to how this was done in the phase 3 trial of atezolizumab/bevacizumab (vs sorafenib), I continue until progression or intolerance. Finn et al., PMID 32402160
Do you recommend 3 months of chemotherapy, 6 months of chemotherapy, or no chemotherapy along atezolizumab in patients with low risk (T1-3, N1) Stage III dMMR colon cancer?
This is a good question (and a data-free zone). pMMR low-risk stage III disease can be treated with 3 months of CAPOX or 6 months of FOLFOX, based on the IDEA trial. The residual risk of relapse for this entity, after chemotherapy, is ~20%. FOLFOX for 3 months was inferior to 6 months by a few perce...