Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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 ...
How would you counsel patients with personal or family histories of autoimmune disease on immune checkpoint inhibitor therapy for Hodgkin lymphoma?
This is also a tough question. I think patients with autoimmune endocrinopathies (especially Hashimoto’s or Type 1 DM) on stable, longstanding replacement regimens, as well as pre-existing vitiligo, are reasonable candidates for frontline PD-1 based therapies, although they certainly bear very close...
How would you counsel patients with personal or family histories of autoimmune disease on immune checkpoint inhibitor therapy for Hodgkin lymphoma?
This is also a tough question. I think patients with autoimmune endocrinopathies (especially Hashimoto’s or Type 1 DM) on stable, longstanding replacement regimens, as well as pre-existing vitiligo, are reasonable candidates for frontline PD-1 based therapies, although they certainly bear very close...
Are you dose reducing/omitting IV dexamethasone as a pre-medication for anti-emesis in patients with MIBC when using durvalumab/gemcitabine/cisplatin?
In my practice, we routinely give IV dexamethasone on the day of treatment. The question is whether or not to give extended dex on days 2-4 to prevent delayed nausea.The NIAGARA protocol did permit dex on the day of the treatment but did state "investigators should attempt to limit the use of steroi...
In patients with recurrent endometrial carcinoma, how do you decide when to offer Carboplatin/Paclitaxel +/- pembrolizumab or dostarlimab (NRG-GY018/RUBY) versus Lenvatinib/Pembrolizumab (KEYNOTE-775)?
I take into account prior therapy regimen in the upfront setting, time to recurrence, burden of disease for pMMR recurrence, and of course, patient characteristics--can they tolerate chemotherapy (again) or how concerned I am about lenvatinib toxicity in said patient? If they have not had chemothera...
How would you treat a patient with TNBC with a residual strongly PR+, ER- breast mass on mastectomy after neoadjuvant KEYNOTE 522 based chemoimmunotherapy?
I would treat such a patient the same way that I would any patient with residual TNBC after neoadjuvant chemotherapy and pembrolizumab, which depends to some extent upon the patient's stage at diagnosis and the extent of residual disease at surgery - in patients with residual disease after neoadjuva...