Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach for endocrine therapy in young women (<35 years old) with HR+/HER2+ breast CA with residual disease after TCHP who will start adjuvant T-DM1?
She would be given the options of tamoxifen or ovarian suppression with an AI for five years and then a discussion at that time based on where the data goes in that time. Tamoxifen would have fewer side effects but less effective reduction of PFS per extrapolation from the SOFT/TEXT trials. Ovarian ...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
How do you approach treatment of a glioblastoma in pregnancy?
Glioblastoma during pregnancy could be treated safely (to mother and fetus) with certain precautions and modifications. Collaboration and consultation with the patient’s obstetrician are essential. External shielding over the patient’s abdomen during treatment will decrease the external scatter radi...
How do you select first-line therapy for PD-L1-positive metastatic TNBC?
For patients with PD-L1 CPS greater than 10, regardless of germline BRCA1/2 pathogenic variant status, my first-line treatment of choice is pembrolizumab combined with sacituzumab govitecan (SG) or chemotherapy based on the ASCENT-04 trial. In ASCENT-04, SG plus pembrolizumab improved median progres...
How do you determine which systemic therapy to recommend in the 2nd line setting for metastatic, PD-L1 NEGATIVE cervical cancer?
This is a very difficult situation because none of the available options are effective. Clinical trial or possibly pembrolizumab on compassion-care usage.
How do you choose 1st line therapy for recurrent cervical cancer?
I use the Moore criteria and if the score is greater than or equal to 2, I will evaluate the patient for contraindications to bevacizumab and if none, I will counsel her to receive bevacizumab plus chemotherapy. The chemotherapy backbone is cisplatin-paclitaxel if the patient did not receive cisplat...
Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?
Tough question, with lots of evolution in this area in the past few years. The data would suggest that for borderline resectable pancreatic cancer, there is a benefit in terms of OS from preoperative treatment. For unresectable disease, the small chance of conversion into resectability is worth the ...
How do you counsel patients and caregivers regarding management of cancer-associated cachexia?
ASCO guidelines re: anorexia/cachexia were just published in May 2020. Basically, they note the magnitude of the clinical problem and the limited therapeutic options proven to be helpful. They state that dietician consultation is reasonable to employ. They also note that it is reasonable for a clini...
Is pembrolizumab considered standard of care in the 2nd line treatment of recurrent cervical cancer?
The phase II Keynote-158 indication is based on objective response of 14% in patients with PD-L1+ tumors. The US FDA approval is accelerated approval meaning that there needs to be a confirmatory trial - this is Keynote 826 which is ongoing.
How do you approach a stage IIIC triple positive IDC, s/p neoadjuvant TCH and P, lumpectomy, and ALND with significant residual disease at the time of surgery?
I would use adjuvant T-DM1 for residual disease after standard neoadjuvant therapy for HER2+ breast cancer as described in this case. We have strong evidence from the KATHERINE randomized trial that adjuvant T-DM1 compared to trastuzumab that cuts recurrence risk by about 50% in this situation. Whil...