Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How will the LORETTA and COMET trials influence your treatment of low-risk DCIS?
Clearly, postop RT can be avoided, but the pink elephant in the room is, can 5 years of endocrine therapy likewise be avoided? Treatment de-intensification requires addressing all aspects of therapy, particularly if one argues against adjuvant therapies for reasons of cost and toxicity. I can't reca...
Do you perform PDL1 and molecular testing for patients with stages I-III NSCLC?
Do you order PDL1 and molecular testing for patients with stages I-III NSCLC?When I answered this question about two years ago, I said no, primarily because there was no Level 1 efficacy data to support an improvement in outcomes for these patients. This has since changed... although in some ways, n...
Do you recommend definitive chemoradiation for unresectable gastric adenocarcinoma in a medically unfit patient?
Definitive is probably not the best term for what can be done. Only palliative doses are possible because the stomach is so sensitive, the GTV is difficult to clearly define, impossible to see on CBCT, the stomach changes shape from day to day, and moves with respiration. There would only be a less ...
How do you interpret nodes with minimal increased uptake on PSMA PET in prostate cancer?
This question is relatively similar to another recent question on indeterminate PSMA PET (#26360), where I provided a longer answer in a bit more detail. The summary is that this essentially relies upon your clinical judgement, and there is no definitive algorithmic way to determine the true nature ...
Has precision medicine changed how you consent patients for treatment?
The use of precision oncology technology and genetics has changed the ability to provide informed consent. In general, the riskier or less standard of care a therapeutic intervention might be, the greater the need for informed consent. In this way, precision oncology has pushed the envelope especial...
Is there any role for ctDNA testing after surgery or SBRT for Stage IB NSCLC to determine the need for adjuvant chemotherapy?
This is another emerging use for ctDNA that has shown promising results in small studies. The TRACERx consortium in the UK looked at the evolution of early NSCLC over time in 100 patients who underwent resection. They performed multi-region sampling and whole-exome sequencing and created patient-spe...
In which situations do you offer ovarian suppression with chemotherapy to prevent the development of premature menopause in premenopausal women with ER negative breast cancer?
I would consider the use of GnRHa during chemotherapy in all women that are premenopausal at breast cancer diagnosis (irrespective of age) and that are concerned about developing the side effects of early menopause. Current evidence supports its use as a standard strategy for ovarian function preser...
Have your treatment recommendations for urothelial cancer patients changed given the ongoing COVID19 pandemic?
The therapeutic approach to cancer patients is changing rapidly due to the COVID-19 pandemic. In discussing with colleagues from several different countries, a few themes emerge. Patient visits, surgery, and treatment that is not essential is being deferred. The benefit/risk that we each consider fo...
Are there circumstances where you would recommend every 6 week dosing schedule for pembrolizumab monotherapy?
FDA approval for q 6 week dosing of pembrolizumab is awaited but has yet to occur; this would represent a welcome change for our patients, as just happened with the recent approval of q 4 week dosing of atezolizumab. Without FDA approval we are not using pembrolizumab 6 week dosing at this time, and...
How do you counsel patients on the efficacy of breast cancer risk reduction strategies such as breast MRI surveillance or bilateral mastectomy for those considered high risk by polygenic risk score, pathogenic variants, and/or family history?
This is a difficult question with limited data to guide decisions. The ultimate goal of any screening effort is to identify disease earlier so that treatment is more effective (and hopefully less onerous) so that fewer patients die. We have good data that enhanced screening in high risk populations,...