Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you recommend ADT or other systemic therapy in patients with rising PSA after prostatectomy and salvage RT and PSMA scan negative for metastatic disease?
Generally, I do not recommend systemic therapy for such patients. If doing so, it would be intermittent ADT (alone) for 6-or 9-month cycles. The EMBARK study will hopefully address this important question.
In which scenarios would you utilize sacituzumab govitecan earlier than third line in the treatment of metastatic TNBC?
To date, we do not have a head-to-head comparison of sacituzumab govitecan prior to the 3rd line setting and insurance approval for sacituzumab govitecan prior to 3rd can be a barrier. However, I consider it under the following circumstances: The patient has significant pre-existing neuropathy. Many...
How do you decide between 1st line PARPi or immunotherapy in a patient with metastatic gBRCA mutated TNBC?
In a patient with a gBRCAm that is PDL1+, I generally consider chemotherapy + checkpoint inhibition in the first line setting given the known survival benefit upfront, and since it is unknown if this benefit with chemotherapy + immunotherapy would be seen in the later line setting. We do have data t...
When do you consider HER2-targeting antibody drug conjugates in the first line setting for metastatic HER2 positive, ER negative breast cancer?
This question cannot be answered for any specific situation with a high degree of reliability without a controlled clinical trial. In my opinion, there could be situations in which I would predict a favorable benefit/risk ratio to the use of T-DXd in first line as opposed to standard taxane + trastu...
How do you utilize CDK 4/6 inhibitors in metastatic ER+ HER2+ breast cancer?
The benefit of adding a CDK4/6 inhibitor to the arsenal of treatment options in the hormone receptor (HR) and HER2-positive metastatic breast cancer setting is unknown. We are trying to answer this question through clinical trials, such as the multi-center Randomized, Open Label, Clinical Study of t...
What second line treatment would you choose for a post menopausal woman with HR+ HER2+ metastatic breast cancer with low burden disease treated with first line aromatase inhibitor and trastuzumab?
The TAnDEM trial did prove that triple-positive metastatic breast cancer should be treated with both anti-HER2 therapy and endocrine therapy. Although there is no direct data in the setting of the above-described case to my knowledge, we can extrapolate from the large body of evidence that exists fo...
For triple positive metastatic breast cancer, is there a role for aromatase inhibitor + CDK 4/6 inhibitor with Her2 directed therapy in a patient that refuses chemotherapy?
Recommend the PATINA trial, a randomized Phase 3 study. open to women or men with HR+, HER2+ metastatic breast cancer following completion of induction with anti-HER2-based chemotherapy. Would not recommend this approach outside of a clinical trial at this time, however.
Would you continue serial PSMA PET scans after 2 negative scans for patients with a persistently rising PSA post-RT?
Some context would probably be helpful for this. E.g., PSA >2 is different for a patient post-prostatectomy vs. post-radiotherapy. But, in general, if clinical suspicion of cancer recurrence/progression is high, and PSMA PET is negative, one can consider the following options: There may not be a ca...
How do you decide the right time to transition to hospice?
Talking about hospice is one of the hardest jobs we have. It's hard because we don't like doing it, because we often don't know how to do it well, and because we angst about doing it too early or too late. It's an important thing to think about. I actually think perhaps the most important factor in ...
Do you use elacestrant for all patients with metastatic ER+, HER2-, ESR1 mutated breast cancer regardless of duration of response to prior ET+CDK4/6i?
Use elacestrant on all patients with ESR1 mutation regardless of length of response