Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In light of the improved outcomes seen in patients receiving IO +/- olaparib, what role, if any, do you think pelvic radiation still plays in the management of patients with advanced endometrial cancer?
The study included a wide spectrum of patients including advance stage with residual disease or recurrent with or without residual disease. Prior RT when indicated was allowed and about 40% had RT as part of care.
How have you incorporated mirvetuximab into the treatment of platinum-resistant ovarian cancer?
This question is going to be increasingly important in the current landscape of ovarian cancer management. I have prioritized early ordering of biomarker testing so that I have the test profiles available at recurrence, particularly in the platinum-resistant standpoint.I find that toxicity, patient ...
If neoadjuvant therapy is indicated for luminal A breast cancer, when do you decide to use chemotherapy versus endocrine therapy?
My practice is to perform recurrence risk assay on biopsy specimen and decide on the choice of neoadjuvant therapy (chemo vs anti estrogen). A clear indication for chemotherapy would not require a recurrence risk assay.
Would you omit radiation for an elderly woman with bilateral breast cancers (both early-stage disease and ER+/PR+/HER2 negative) who otherwise meets the criteria for endocrine therapy alone?
Yes. If the patient meets omission criteria on each side individually, then I offer omission to the patient overall as part of shared decision-making, although it is conceivable that the absolute benefit of radiation is doubled in this scenario. As usual, this assumes the patient will be compliant w...
Should testing for genetic causes of HLH be performed in all patients with MAS or secondary HLH regardless of the patient's age?
Familial HLH (fHLH) is a pediatric disease. Therefore, there is no place for genetic testing to establish a diagnosis of fHLH in adults, and treatment for HLH should not be delayed while waiting for genetic testing. However, there are hypomorphic polymorphisms in the fHLH genes that may be a contrib...
What is the appropriate workup and treatment for patients with SMART syndrome following radiation for brain tumors?
Stroke-like migraine attacks after radiation therapy (SMART) is a late presentation after treatment for a CNS malignancy (or brain radiation for another cause; e.g., prophylactic cranial radiation). It is one of many late effects of radiation therapy. Others may include vasculopathy, cognitive dysfu...
Would you recommend lymph node biopsy in a patient with SCC of the right ventral tongue (~1 cm) post excision with close margins and no noted adenopathy on imaging?
For patients with oral cavity cancers, a neck dissection is generally warranted. Hence, I would not recommend a node biopsy but rather refer the patient back to the surgeon to have a selective neck dissection performed. Since the patient underwent surgery of the primary lesion in the anterior tongue...
In an N+ rectal adenocarcinoma treated via PROSPECT with neoadjuvant FOLFOX with omission of CRT and no treatment response in the primary on pathology (ypN+), would you offer adjuvant chemotherapy or chemo-radiation?
Adjuvant FOLFOX was allowed in PROSPECT, and most patients received it. Presumably, patients with ypN+ disease were most likely to receive adjuvant FOLFOX. We do not (yet) have recurrence data broken down by ypN stage, but as the overall LR rate was less than 2%, I would not consider the lack of his...
Do you offer adjuvant durvalumab for stage I small cell lung cancer following SBRT or surgery?
Obviously, there are no direct data, and the standard is EP chemotherapy. The cure rate in this situation is still suboptimal, but the majority of patients are cured. Adding IO might improve survival, but will most certainly increase cost and toxicity. I would discuss with patients, and I often tell...
Would you treat PASH (pseudoangiomatous stromal hyperplasia) with focal ER positivity with hormonal agents?
I would not offer endocrine therapy to a woman with PASH. PASH is a benign breast disease and is felt to be mediated by hormonal induced stromal change, hence the ER positivity. Endocrine therapy is offered to women with high risk breast lesions (LCIS, ADH, ALH, etc) primarily to reduce the risk of ...