Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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 ...
Which chemotherapy should be held while delivering palliative radiation?
Any chemo that is considered a radiosensitizer should be considered as potentially increasing toxicity during palliative RT, and the question of whether to hold these agents should be carefully considered at the very least. This includes but is not limited to: doxorubicin, gemcitabine, taxanes, 5FU,...
What data support the use of continuing GnRH therapy "backbone" in metastatic castration resistant prostate cancer (mCRPC) receiving additional therapies?
The short answer is that ALL phase 3 trials of life-prolonging therapies now approved in mCRPC required ongoing ADT (medical or surgical) and there is not a single positive life-prolonging phase 3 trial that did not do this. Until then our strongest evidence is to follow how these trials were conduc...
How do you sequence capecitabine and olaparib, if at all, in patients with BRCA+ TNBC and residual disease after neoadjuvant chemotherapy?
Patients with germline PV in BRCA 1/2 and residual disease following NAC in early TNBC have two options that likely represent standard of care in the adjuvant setting, a) adjuvant capecitabine (CREATE-X, EA1131) and/or b) adjuvant olaparib (NSABP B55). B55 did not allow for any further adjuvant chem...
Are there instances where you can defer on mass spectrometry testing for amyloid typing in Congo Red positive tissue?
This is a great question and one that is not uniform in its answer depending on the clinical situation.Assuming we are talking about at diagnosis here, the short answer is always send Congo red positive bone marrow findings for mass spec typing if there is enough positive protein to dissect and type...
How do you follow pulmonary embolism patients who have completed anticoagulation?
3 months after sustaining an acute PE, I asked the patients if they were back to their pre-PE level of functional capacity. If they are not, i.e. if they remain dyspneic, I get an echocardiogram and a VQ scan. If the echo during the acute PE shows RV strain or evidence of pulmonary hypertension, I r...
In a patient with primary mediastinal seminoma with normalization of biomarkers s/p EPx4 and residual non-FDG avid mass, would you consider resection of residual tumor vs surveillance?
Patients with a primary mediastinal seminoma will have > 90% cure rate with chemo alone, but will ALWAYS have a residual mass. Assuming the initial serum AFP was normal and pathology was definitive that this was ONLY seminoma, we would not even do a PET scan but just observe with serial CT scans, H ...
Is there still a role of brachytherapy in uterine cancer if intensity-modulated radiation therapy is available?
Yes. Brachytherapy is still more conformal than optimally planned IMRT.
How do you interpret NIAGARA efficacy given that adjuvant nivolumab was not administered in the comparator arm?
The NIAGARA trial evaluated the role of durvalumab as neoadjuvant/adjuvant treatment in muscle-invasive bladder cancer (MIBC). The combination chemoimmunotherapy (cisplatin, gemcitabine, and durvalumab) was given for 3 months prior to radical cystectomy, followed by adjuvant durvalumab every 4 weeks...
How would you manage a solitary unresectable liver metastasis?
Excellent question! Before starting any systemic treatments, has the patient undergone an MRI? Conducting an MRI prior to systemic therapy is crucial for accurately determining whether there are single or multiple liver metastases. The CAMINO study has shown that incorporating an MRI at the initial ...