Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?
Though some clinicians have been exploring the idea of targeted therapy for EGFR mutant brain metastases, this has been done in the absence of strong evidence. Reasons for pushing this idea are that sometimes the lesions seem to respond, and this has been seen in some single arm studies and anecdota...
Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?
This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this s...
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...
How does data from the HIMALAYA trial impact your first line treatment selection for advanced HCC?
The results from the HIMALAYA trial with the combination tremelimumab (CTLA-4 inhibitor) and durvalumab (PD-L1 inhibitor) reported an OS of 16.4 months compared to 13.8 months for sorafenib which was statistically significant (HR 0.78, p-value of 0.0035). With the limited data presented at ASCO GI 2...
Would you recommend 3 or 6 months adjuvant chemo for low risk Stage III sigmoid cancer (T3/N1), but with positive LVI and PNI?
I would recommend 3 months of CAPOX in this case. For a patient with stage III colon cancer, the presence of LVI and PNI should not influence the treatment plan.
What neoadjuvant therapy would you choose for a post menopausal woman with ER negative, PR positive high grade node negative breast cancer?
Assuming that there is no reason to doubt the results of the hormone receptor testing, and her HER2 is negative, I would treat her the same way I would a triple-negative cancer—I would not bother to send Oncotype as it should be high with the negative ER, and I wouldn't believe it if it came back lo...
Do you recommend ovarian suppression in all premenopausal women under age 35 with ER positive breast cancer based on the SOFT/TEXT data, regardless of other risk features?
I do not recommend ovarian suppression on all women under 35. Like any intervention, we need to know the absolute risks of recurrence with and without the intervention. For these reasons, given the side effect profile of ovarian suppression in younger women, I usually reserve it for women with large...
Do you consider MSI testing for mCRPC?
I agree that data for response to immunotherapy in MMR-deficient (dMMR) prostate cancer is limited, and we estimate the rate of dMMR in prostate cancer to be low, in the 2-3% range. Nonetheless, based on responses in other dMMR tumors, pembrolizumab is now FDA approved for all dMMR/MSI-high unresect...
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.
For women who have had either embryo or oocyte cryopreservation, do you also recommend administering GnRH analogs?
For anyone who is interested in fertility preservation enough to undergo egg or embryo cryopreservation, I think offering GnRH analog treatment through chemotherapy for prevention of premature ovarian insufficiency and potentially infertility makes sense. Although some women may not want to deal eve...