Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
How would you approach adjuvant therapy in a patient with HR+ breast cancer with a high RS (>25) given the current COVID-19 pandemic?
The starting point for consideration of adjuvant chemotherapy is to quantify the risk of a distant recurrence. For estrogen receptor positive, HER2 negative breast cancer, Oncotype Dx RS data are critical for understanding the risk of a distant recurrence1 as well as endocrine and chemotherapy respo...
How do you manage a delayed cutaneous reaction to docetaxel after the first cycle of adjuvant TC in early-stage HR-positive, HER2-negative breast cancer?
There is excellent guidance in the literature on management of drug-induced rashes in these patients in Sibaud et al., PMID 27550571. Management generally involves topical and if necessary systemic steroids. I particularly like using lotion versions of topical steroids such as triamcinolone as they ...
Would you consider restarting IMID therapy in a patient with recent stroke while on IMID?
This is a very good question, and practice likely differs across institutions as data is limited. The discussion below refers primarily to the immunomodulatory (IMID) agents lenalidomide and pomalidomide.As you are aware, IMID therapy is known to be associated with an increased risk for venous throm...
When using T-DXd/pertuzumab regimen in frontline treatment of HER2+ metastatic breast cancer, are you adapting the regimen with induction and then de-escalation to maintenance?
Outside of a clinical trial, I do not routinely define a fixed induction-and-maintenance strategy when starting T-DXd with pertuzumab. Instead, I individualize treatment over time based on response, tolerability, and patient priorities. While many patients achieve deep and durable responses, cumulat...
Do you consider NSCLC with multistation N2 involvement appropriate for treatment with neoadjuvant chemoimmunotherapy followed by surgery?
Interesting question and something that is frequently discussed in tumor boards. Multistation N2 patients were not included in neoadjuvant trials and hence, any adaptation of this strategy to patients with advanced N staging would not be appropriate at this time. Further, given level 1 evidence from...
When would you offer post-operative concurrent chemoradiation in anaplastic thyroid cancer?
The management of ATC has evolved considerably over recent years with the most significant being a dichotomy of management based on Braf mutation. We typically offer postoperative XRT, including in patients with either a limited or stable DM disease. However, in a multidisciplinary setting, there so...
How will the LORETTA and COMET trials influence your treatment of low-risk DCIS?
Clearly, postop RT can be avoided, but the pink elephant in the room is, can 5 years of endocrine therapy likewise be avoided? Treatment de-intensification requires addressing all aspects of therapy, particularly if one argues against adjuvant therapies for reasons of cost and toxicity. I can't reca...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...