Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to adjuvant endocrine therapy in hormone receptor positive male breast cancers?
Tamoxifen should be the standard adjuvant endocrine therapy for ER+ breast cancer in men. There has been talk intermittently about aromatase inhibitor (AI) use as alternative endocrine therapy, and I would not recommend the use of AIs in this setting. Data is limited, with the one study comparing ou...
What imaging surveillance for ILD do you utilize for patients with HER2+ breast cancer receiving adjuvant T-DXd?
I follow the protocol as described in DESTINY-Breast05 (Loibl et al., PMID 41370739):For patients who received adjuvant radiotherapy, monitoring for asymptomatic or mildly symptomatic therapy-related interstitial lung disease or pneumonitis included serial low-dose CT of the chest at 6 weeks after t...
Do you always send SDHB by IHC for workup of GIST or is NGS that includes SDHB sufficient?
In the appropriate clinical presentation, with negative KIT and PDGFRA, NGS that includes SDH should be sufficient to define the entity.
What is your approach to recurrent metastatic high-grade uterine carcinosarcoma with rhabdomyoblastic differentiation?
Carcinosarcomas (even with rhabdomyoblastic differentiation) are still considered to be derived from endometrial tissue. I would treat it as endometrial cancer and not as uterine or soft tissue sarcoma.
Would you consider circulating DNA assay in resected node-negative deficient MMR colon cancer off-trial to guide your treatment?
Hello. It appears you are asking about a stage II MMR deficient/MSI-High colon cancer. The recurrence rate for stage II mismatch repair deficient (dMMR) colon cancer is generally lower than that for mismatch repair proficient (pMMR) tumors. Studies have shown that the 5-year recurrence rate for stag...
What is your approach to systemic therapy in newly diagnosed colon cancer with synchronous solitary liver metastases?
This is an important and challenging clinical question. In general, I favor a neoadjuvant chemotherapy treatment approach for a variety of reasons. For one, the EORTC trial provides us with supportive data that perioperative FOLFOX is associated with a modest improvement in outcome compared to surge...
If a BRAF-mutated melanoma patient developed metastatic disease progression on adjuvant anti-PD-1 monotherapy, do you recommend switching to BRAF/MEK targeted therapy or combination immunotherapy?
The developing pre-clinical and clinical data is clear on this and I believe it becomes even more clear with time. While the DREAMseq study did not enroll patients following adjuvant therapy as the patient in the case, the overall evidence clearly shows that BRAF/MEK inhibitor resistant melanomas ar...
How do you manage monitoring menopausal status for a premenopausal patient with DCIS on tamoxifen who would likely become post-menopausal during therapy?
Monitoring menopausal status in premenopausal women on tamoxifen is relatively easy, even if the tamoxifen interrupts their menstrual cycles, or they have had a hysterectomy but still have at least 1 ovary. Since tamoxifen doesn't lower estrogen levels the way aromatase inhibitors do, you can simply...
How do you choose between Atezolizumab/Bevacizumab (IMbrave 150) versus Durvalumab/Tremelimumab (HIMALAYA) versus Ipilimumab/Nivolumab (Checkmate09DW) in first-line metastatic hepatocellular cancer?
I use a range of factors, discussed here and here, when deciding between atezo/bev and STRIDE regimens in my patients with advanced HCC.Summarily, both regimens demonstrated clinical benefit in patients with advanced HCC with side-effect profiles expected for the individual agents. The choice of reg...
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...