Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant treatment would you use in a pT1miN0M0 ER -/HER2 IDC of the breast after bilateral mastectomies?
I generally would not treat microinvasive disease with systemic therapy unless it were multifocal in a surrounding of high grade DCIS, as these cases could recur distantly, although even then, the risk is low. It may be higher over a life time in younger patients - with 20 year breast cancer mortali...
How aggressive would you be in irradiating asymptomatic bone metastases in a patient with metastatic prostate cancer?
I used to tell patients who were referred to me for asymptomatic bone mets to defer treatment until they began having pain (unless there was an impressive radiographic lesion or concerns of impending pathologic fracture or cord compression). But the multicenter, randomized trial presented at the Ame...
What is your preferred third line treatment option for metastatic NSCLC after first line chemo-immunotherapy and second line single-agent chemo (assuming no actionable mutations)?
What a question! One that has no answer, I'm afraid. This is exactly where we were five years ago before the advent of immunotherapy as a treatment for NSCLC. Then -- as now -- the best answer for a patient with a good performance status was a clinical trial. If for whatever reason a clinical tria...
How would you approach a clinical stage 3 sigmoid colon cancer, dMMR/MSI-H with comorbidities and increased risk of surgical complications?
For patients with dMMR/MSI-H clinical stage III sigmoid colon cancer, the current practice would be upfront surgery, and usually, most patients should be able to tolerate the minimally invasive surgical approach. If the patient is not a surgical candidate due to comorbidities with increased risk of ...
Is there data to support a 3 weeks regimen of panitumumab with maintenance capecitabine in colon cancer?
Although the most commonly used dosing for panitumumab is 6 mg/kg every 2 weeks, the serum panitumumab concentration was similar in the 2.5 mg/kg weekly, 6.0 mg/kg every 2 weeks, and 9.0 mg/kg every 3 weeks in the phase 1 study (Weiner et al., PMID 18223225). A phase 2 study using panitumumab and ir...
Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?
Great question.There are two questions here:Question 1. Should we treat an unresectable MSI-H colon cancer patient with immunotherapy? The answer is yes, based on the data we have from metastatic disease trials such as KEYNOTE-177 and CheckMate 142 studies. We can also use the phase 2 study data fro...
How do you treat refractory cold agglutinin disease?
If the patient has refractory cold agglutinin disease not associated with malignant lymphoproliferative disease, I have used intermediate dose Cytoxan. However, there is recent evidence that inhibition of C1s and thus complement activation by a monoclonal antibody sutimlimab markedly reduces hemolys...
Would you consider using CDK 4/6 inhibitors in a patient with end stage renal disease (ESRD) along with an aromatase inhibitor?
The short answer is yes. Here is why...All three CDK4/6 inhibitors are extensively metabolized by the liver and excreted in the feces. Based on the known PK profiles of all 3 commercially available CDK4/6 inhibitors, there should not be a dose reduction necessary in patients with CKD (although these...
When would you consider adjuvant fulvestrant for ER+ breast cancer if the patient does not tolerate tamoxifen or any of the AIs?
While there are no trials that have assessed adjuvant fulvestrant versus placebo, we know from a small trial (GEICAM 2006-2010) that adjuvant fulvestrant plus anastrozole doesn’t add much when compared to adjuvant anastrozole. In this clinical setting, if the risk for distant recurrence is very high...
Is it appropriate to offer definitive trimodality therapy, as an equivalent option to neoadjuvant chemotherapy followed by radical cystectomy, in patients with muscle-invasive bladder cancer regardless of fitness or platinum eligibility?
There are now several retrospective studies utilizing advanced statistical techniques suggesting that outcomes after trimodality therapy (TMT) are very similar to those after surgery (e.g., Zlotta et al., PMID 37187202, Brück et al., PMID 37517601, and Kulkarni et al., PMID 28410011). These findings...