Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to adjuvant endocrine therapy in high-risk premenopausal women with ER/PR+ Her2+ breast cancer?
There are no large scale modern era assessing the role of adjuvant hormonal therapy in patients with HER2+ and hormone receptor positive breast cancer. Data from metastatic trials and cohort studies do suggest that there is an interaction with concurrent hormonal and HER2-targeted therapy and the tw...
How do you decide between RPLND vs. chemotherapy in patients with Stage IIA mixed germ cell tumor as primary treatment?
I agree but would add a few comments: If there is a rising hCG or AFP above normal values, we prefer BEP X 3 rather than RPLND. If the patient > age 50, EP X 4. Also, we consider any AFP < 25 to be “ normal” despite many labs listing 0-8 as their normal range. Our group recently published data in J...
What is the optimal approach to managing oral toxicities, such as dysgeusia, caused by immune checkpoint inhibitors (ICIs)?
Unfortunately, this is a very strange side effect of ICI. I have seen this a few times in my clinic, and mechanistically, in my humble opinion, this is a neurologic irAE. I also notice patients losing tremendous amounts of weight due to the inability to taste and eat food. There is no good fix for t...
How do you monitor and manage minimal residual disease (MRD) in patients with core-binding factor (CBF) AML who are in remission post-induction and consolidation therapy?
For the purposes of this question, we will presume this refers to patients who are MRD-negative by a PCR-based methodology and have completed induction chemotherapy and consolidation.Puckrin et al., PMID 31896684 reported on 114 patients with CBF-AML who were treated with intensive chemotherapy and ...
How do you monitor and manage minimal residual disease (MRD) in patients with core-binding factor (CBF) AML who are in remission post-induction and consolidation therapy?
For the purposes of this question, we will presume this refers to patients who are MRD-negative by a PCR-based methodology and have completed induction chemotherapy and consolidation.Puckrin et al., PMID 31896684 reported on 114 patients with CBF-AML who were treated with intensive chemotherapy and ...
How would you treat a patient with newly diagnosed ALK+ Stage IIIB non-small cell lung cancer (NSCLC)?
Stage IIIB encompasses T3-4N2 and T1-2N3, so I will assume that we are not going to consider a neo-adjuvant approach. Standard treatment for stage IIIB ALK+ NSCLC would be definitive concurrent chemo/RT given with curative intent. Reasonable chemo regimens would be weekly carboplatin plus paclitaxel...
How would you approach a young patient with oligometastatic inflammatory triple negative breast cancer with bone only metastases?
There is no clinical trial data to provide solid guidance on how to manage oligometastatic de novo stage IV disease. We learned that surgery to the primary tumor without ablating distant mets and giving multidrug adjuvant-like systemic therapy does not improve survival. We also learned that SBRT to ...
When do you recommend incorporating HER2 testing into the diagnostic pathway for tumor types where HER2 overexpression is not commonly assessed?
I would recommend HER2 IHC testing at the time of advanced cancer diagnosis or at the next therapy change, whenever HER2-targeted therapy would be considered in the treatment course.
How would a low tumor mutational burden (<10) influence your decision to offer neoadjuvant immunotherapy for cutaneous squamous cell carcinoma?
I do not think TMB is a perfect biomarker to predict response to checkpoint inhibition. Having said that, we certainly can't ignore it. For patients with head and neck CSCC, I prefer using neoadjuvant immunotherapy without checking for biomarker/TMB status, as these are usually sun-damaged, inflamma...
How frequently would you consider IV iron treatment for ongoing iron loss and severe iron deficiency anemia?
Absolutely. You first want to estimate and replace their iron deficit. For patients who are very anemic, they can start at 2-3 grams deficit. I usually don’t give more than 1500 g of iron dextran at one time, but I will have no concern about doing 1000 or 1500 mg weekly until I have replaced their d...