Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.
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,...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
What is optimal endocrine therapy in a young, premenopausal women with ER/PR positive oligometastic breast cancer successfully treated with curative intent neoadjuvant chemo followed by surgery+RT to skeletal oligomet?
These cases are always important to understand what discussions were had up front with the patient and all members of the team regarding goals of care. It seems the patient was treated with "curative" intent; however, the likelihood that she has actually been cured of her disease is extremely low an...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
How would you integrate immunotherapy into the treatment of a patient with recurrent, widely metastatic gastric adenocarcinoma after initial treatment with perioperative EOX and subtotal gastrectomy?
I agree with my friend, @Dr. First Last. Firstly, I hope that this is an entirely theoretical scenario or that the patient received EOX many years ago, prior to the FLOT4 data that established FLOT as the current standard-of-care. As Dan also mentioned, for patients who cannot tolerate FLOT, FOLFOX ...
Is there any data on the use of PARP inhibitors in patients with metastatic urothelial carcinoma with deleterious DDR mutations?
Urothelial cancers harbor high rate of deleterious DDR alterations. Based on clinical data from other tumor types, especially TOPARP-A in metastatic castration-resistant prostate cancer where responses to olaparib monotherapy were observed especially among men with defective DDR genes, the use of PA...
Do you discontinue an aromatase inhibitor in a patient if they have a cardiac event while on the drug?
Randomized clinical trials and several meta-analyses that compared tamoxifen with aromatase inhibitors (Khosrow-Khavar et al., PMID 32065766 is a more recent one) demonstrated statistically significant increase in the rate of cardiovascular events in women taking aromatase inhibitors although the ab...
When do you suggest ovarian suppression for fertility preservation in premenopausal women receiving neo/adjuvant chemotherapy?
The benefit of ovarian suppression in young breast cancer patients should be looked into from two different aspects. First, the suppression of the ovary resulting in the hormone receptor-dependent cancer stem cell (minimal residual disease) suppression, and second, the preservation of the fertility ...
In patients with cancer of unknown primary, do you routinely send molecular testing to help determine primary tumor origin?
The NCCN designates tumor sequencing and use of gene signature profiling as a category 3 recommendation. This is more or less consistent with NIH and ESMO guidelines in that that the impact on patient outcome remains questionable and unproven.There are multiple commercial assays in this space. The p...