Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you assess and counsel women with chronic post-lumpectomy or mastectomy pain?
Post-surgical breast pain is not uncommon. Estimates suggest that 25-60% of patients having breast surgery experience persistent pain, with symptoms lasting from months to years following breast cancer diagnosis and treatment (Langford et al., PMID 25439318; Gartner et al., PMID 19903919).Initial as...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...
For patients undergoing bladder preservation therapy with trimodal therapy, how do you manage the urinary urgency and frequency during and after treatment?
This can be a difficult problem to manage because I try to avoid treatment interruption if at all possible, which is different from my approach in patients with prostate cancer, where treatment interruption is a safe and effective alternative. In patients with bladder cancer, the first thing I will ...
Would you recommend radiation or chemoradiation in a patient with cholangiocarcinoma s/p surgery and adjuvant treatment with single hepatic metastasis 3 years later?
Challenging case and worthy of tumor board discussion. I would likely start systemic therapy, and if response, consider regional therapy with resection or SBRT, assuming the hepatic function is adequate (keep in mind, TARE can cause liver disease). I have one patient in a similar situation, now > 5 ...
Would you offer neoadjuvant chemotherapy to premenopausal women with cT1cN0 HER2+ breast cancer?
Since most neo-adjuvant trials required that primary tumor was at least 2 cm, I tend to lean towards upfront surgery. If the tumor size is confirmed and sentinel lymph nodes are negative, the patient could be offered paclitaxel and trastuzumab which is significantly less toxic than pertuzumab in com...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
In which situations do you offer ovarian suppression with chemotherapy to prevent the development of premature menopause in premenopausal women with ER negative breast cancer?
I would consider the use of GnRHa during chemotherapy in all women that are premenopausal at breast cancer diagnosis (irrespective of age) and that are concerned about developing the side effects of early menopause. Current evidence supports its use as a standard strategy for ovarian function preser...
For patients with EGFR mutation positive NSCLC who progress on first line TKI without actionable resistance mechanisms, would you consider chemotherapy + targeted therapy as a second line option, or chemotherapy +/- immunotherapy?
This is certainly not an easy question. Assuming that the patient doesn't have an actionable targetable mutation, two important things that may be helpful to know in such cases are disease behavior and the status of disease in the brain. If the disease is behaving aggressively, we SHOULD ALWAYS rule...
Does the presence of cribiform histology at biopsy in prostate cancer affect your management in an otherwise intermediate-risk prostate cancer?
There have been no trials on this specific question, so there is room for debate and more science (hoping our recent grant submission in this area gets funded...). Here is my current thinking. This is for generally healthy patients with long life expectancy (≥10 years, but especially if ≥15 years). ...