Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat a locally advanced cervix cancer in a patient who declines brachytherapy?
You provide this lady with a curable disease the appropriate social support, mental health support, and transportation coordination in order for her to complete curative treatment with brachytherapy. Anything short of that in America with all our incredible resources and care options is substandard ...
When, if ever, would you recommend hysterectomy after chemoradiation for patients with locally advanced cervical cancer?
We would never offer a routine hysterectomy unless a planned dose of RT can’t be derived for various reasons (very rare). If the patient has persistent disease after chemo RT, then they are considered for hysterectomy or exenteration based on extent of residual disease and surgical feasibility.
What is optimal therapy for a 5 year delayed recurrence of uterine cancer, rendered NED by solitary pulmonary metastasis resection?
I favor “pseudoadjuvant” therapy with carboplatin + paclitaxel chemotherapy for 6 cycles. I make this recommendation in the absence of strong data to suggest an improvement in outcome with chemotherapy over observation vs. hormonal therapy. The optimal therapy for this patient with recurrent endomet...
If a patient with HER2+ uterine serous carcinoma recurs while on maintenance trastuzumab, would you continue trastuzumab with second line chemotherapy?
I advise against extrapolating data from breast cancer therapies to endometrial cancer. There is no clinical trial supporting the administration of trastuzumab (or other anti-HER2 therapy) with second line chemotherapy after progression on maintenance trastuzumab in serous endometrial cancer. Rather...
Would you recommend olaparib for a patient with germline BRCA1 mutation and HER2+ metastatic breast cancer who has progressed through multiple lines of HER2-directed therapy including trastuzumab deruxtecan?
Although OlympiAD (Robson et al., PMID 28578601) and EMBRACA (Litton et al., PMID 30110579) studied olaparib and talazoparib in HER2negative gBRCA mutant metastatic breast cancer, the activity is based on the mechanism of synthetic lethality in BRCA deficient tumors. Thus, it is reasonable to think ...
How would you treat a recurrent endometrial cancer at the vaginal cuff that was initially FIGO 1A with no adj treatment, in a patient with actively treated scleroderma?
I would favor brachytherapy alone using MRI based planning with either a multichannel or hybrid applicator. Dose 6 Gy x 6 to CTV and higher dose (hot spots) to GTV.
How does positive p53 staining influence your recommendation for adjuvant therapy in comprehensively staged early (stage IA or IB), grade 2, endometrioid endometrial cancers?
It does not influence my recommendations. If a study is available to potential study the risk conferred by P53, I would offer it to my patient.
Are there differences in T-DXd efficacy along the spectrum of HER2 IHC expression to impact treatment decisions or sequencing?
There do not appear to be differences in T-DXd efficacy along the spectrum of HER2 expression in these low HER2-expressing tumors as seen in Figure S2 and Figure S4. Reviewing the waterfall plot (Fig Supp 4), we see complete responses in approximately as many patients with IHC 1+ as those with IHC 2...
If a patient is unable to tolerate one CDK 4/6 inhibitor, do you switch to a different one?
There are currently no data about switching from one CDK 4/6 inhibitor to another. The current recommendations for palbociclib with grade 3 neutropenia and infection are to hold palbociclib until recovery to grade 2 or less and then dose reduce. It sounds as though this patient has required multiple...
How do you decide on adjuvant therapy in a patient with a Stage IA uterine carcinosarcoma without any myometrial invasion?
There is no good prospective study. Our approach, based on outcome and retrospective data (including NCDB), is brachy plus chemo. https://www.ncbi.nlm.nih.gov/pubmed/30170976This is paper I was referring to. With all the caveats of NCDB studies, it givess some objective information where prospective...