Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
When should you use single-fraction radiotherapy for spinal cord compression?
The SCORAD III trial is practice changing. But I do NOT plan to treat ALL patients with spinal cord compression with a single fraction of 8 Gy now. Here is why: SCORAD III is extremely important new study for the management of metastatic epidural spinal cord compression (MESCC) for patients with sho...
Is there a correlation between rectal cancer stage and dose response to radiotherapy?
Possibly. While some compelling data from Appelt et al. in 2013 reflected there may be a correlation between RT dose and rectal tumor response (Appelt et al., PMID 22763027), an extensive number of prospective trials examining the influence of boost doses of RT on pathologic response have produced m...
How do you choose first or second-line systemic therapy for fibrolamellar hepatocellular carcinoma?
Fibrolamellar carcinoma is histologically unique from hepatocellular carcinoma. The disease is correctly called fibrolamellar carcinoma, and not fibrolamellar hepatocellular carcinoma, or hepatocellular carcinoma fibrolamellar variant. Even though the latter may be permissive if the lack of cirrhosi...
What is your strategy for ovarian suppression if unable to achieve goal estradiol levels with leuprolide 3.75mg monthly dose?
Monthly therapy rarely fails to induce adequate suppression. The choice of options will depend on whether the patient planned permanent or only temporary suppression AND the risk of recurrence of the cancer. If she will accept permanent suppression and has high risk disease, oopherectomy would be th...
After WBRT, what systemic therapy would you favor for maximal CNS penetrance in a patient with triple negative metastatic breast cancer and multifocal CNS disease?
With patients such as this, I would usually recommend the following: 1. Genomic testing (Strata, Foundation 1, etc.) to look for a mutation that might be targetable with a TKI that crosses the blood brain barrier well 2. Re-testing of the CNS cytology for HER2, given that we do have multiple drugs w...
What is your preferred first line treatment option for a fit patient with non-squamous NSCLC who is PDL1 positive (1-49%) with no driver mutations?
My preferred first line option for patients with advanced NSCLC and PDL1 TPS score of >1% and <50-% remains chemotherapy with immunotherapy. I prefer carboplatin- pemetrexed -pembrolizumab for nonsquamous and carboplatin-taxane-pembrolizumab for squamous cell NSCLC. I might consider Nivolumab Ipilim...
In which group of patients you would send for RNAseq for translocations/fusions that might be missed by NGS in advanced NSCLC?
In patients who are never/rare smokers in whom tissue NGS is negative, I would strongly consider RNAseq of a recent or fresh biopsy. You can find the occult fusion (or missed MET) in about 15% of NGS negative, TMB low cases based on this recent very nice paper from MSKCChttps://www.ncbi.nlm.nih.gov/...
Do you recommend routine surveillance MRI brain for asymptomatic patients with metastatic HER2+ breast cancer?
I do not perform routine screening or surveillance MRI of the brain for asymptomatic patients with HER2 positive metastatic breast cancer. But I do have a low threshold to order brain imaging in such patients for early/minimal symptoms. My reasons for not performing routine screening/surveillance MR...
What would you use as adjuvant endocrine therapy for a patient who developed an invasive, hormone receptor positive breast cancer while on raloxifene for almost a decade prior?
In this situation I would use an aromatase inhibitor if possible. One would not expect an ESR1 activating mutation to be readily detected after treatment with a SERM, since estrogen deprivation rather than receptor blockade enriches for ESR1 mutant clones.