Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any role for PARPi maintenance in BRCA-/HRD- patients after response to front line chemotherapy +/- bevacizumab?
This is a more complex question, and relies on a conversation with the patient and shared decision making. Unfortunately, the benefit seen with PARPi maintenance in BRCA-/HRD- patients was limited (PRIMA 8.1 vs. 5.4 months; PAOLA-1 16.9 vs. 16 months). I am also sensitive to implications of incorpor...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?
For patients with T3N0 upper rectal cancer with no significant risk factors (R0, CRM clear, no EMVI) who undergo high quality TME surgery as suggested by an intact TME pathologic specimen, the 5-year risk of pelvic recurrence without the delivery of adjuvant radiotherapy is < 5%. I do not recommend ...
For a patient with well differentiated de novo triple positive metastatic breast cancer who did not respond to THP, do you sequence all available HER2 targeted options before endocrine therapy?
Endocrine combinations for triple positive breast cancer are honestly a bit understudied. We are starting to get more data in this space, SUMMIT, for example, neratinib + fulvestrant + trastuzumab. I think endocrine based combinations are very interesting and there are likely some tumors that are mo...
Would you consider omitting platinum from neoadjuvant chemotherapy in women > 50 years of age with localized triple negative breast cancer?
I would not use the results cited above from the >50 subgroup (which was just 30% of their study population) of the study from the Tata Memorial Centre to justify omission of carboplatin from the neoadjuvant regimen for TNBC in otherwise healthy patients over 50 with TNBC. There is compelling data f...
How would you treat patient with a stage IV lung adenocarcinoma, an exon 21 p.H835L mutation, high TMB, and negative PD-L1?
EGFR H835L mutation is a rare variant that is in Ex21 of EGFR. Though there is not a lot of data with this particular mutation, the available data suggest that it is a sensitizing mutation with a few case reports suggesting that patients harboring these mutations have a good outcome with EGFR TKI. T...
How would you manage symptomatic superficial vein thrombosis during pregnancy?
The best evidence for the treatment of SVT comes from the CALISTO trial, which endorsed a prophylactic dose of fondaparinux as the treatment of choice. However, the CALISTO trial excluded pregnant women. Because data on the use of fondaparinux in pregnancy remain limited, with some traces of fondapa...
How long would you recommend a woman with HR+ node-positive breast cancer treated with surgery and chemotherapy during pregnancy can breastfeed, prior to starting adjuvant endocrine therapy?
I agree. This is unfortunately, an area with a lack of data, though in my experience, most women who are treated for breast cancer during pregnancy are still in the middle of therapy (systemic or local) after delivery, so we typically recommend against breastfeeding to avoid delays, particularly wit...
What are your top takeaways from ESMO 2023?
Lung Cancer New first line therapy for advanced EGFR Exon 20 NSCLC patients: The PAPILLION trial [Zhou et al., PMID 37870976] was a Phase 3 clinical trial among patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC) with documented epidermal growth factor receptor (EGFR) ex...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...