Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How should we address the questions about the use of hormone replacement therapy in post-menopausal women who have concerns about its relation to breast cancer?
I am presuming that we are referring to woman that does not have breast cancer. Overall, long term estrogen replacement, especially combined with a progestin, is used much less these days since the Women's Health Initiative trials found an increases in coronary heart disease (CHD), breast cancer, pu...
How do you approach patients who progress on maintenance atezolizumab after platinum based chemotherapy for extensive stage small cell lung cancer?
At this time I have not yet had this experience. However, the approach should not be very different from that of treating a patient who has progressed after initial chemotherapy with platinum/etoposide who are on observation after having completed 4-6 cycles. If there has been a significant interval...
In what circumstances would you stop therapy for patients with metastatic HER2+ breast cancer with long-term complete response to HER2-directed therapy?
When a patient is having a very durable and long-term response to HER2-directed antibody therapy, I would typically stop the therapy only if issues related to it (such as decreased EF) arise or if the patient desires to stop. To my knowledge, there are no great retrospective reviews or studies guid...
For patients with metastatic adenocarcinoma of the lung, do you base any treatment decisions on EGFR gene amplification?
There are no proven predictive uses for EGFR amplification in lung cancer. In a negative trial of necitmumab, patients with EGFR amplification had a positive outcome in the EGFR amplified subset, but this was an unplanned analysis and is thus hypothesis generating rather than proven. The hypothesis ...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...
How would you manage a recurrent uterine leiomyosarcoma, now status post secondary cytoreduction, with no gross residual disease?
NCCN guidelines recommend that isolated metastases that have been resected can be considered for treatment with postoperative systemic therapy and/or postoperative external beam RT. Observation is also an acceptable alternative for those who have no evidence of disease on postoperative imaging. This...
What is your approach to management of a subtotally resected pineal parenchymal tumor of intermediate differentiation (CNS WHO grade 2)?
In full disclosure, I have had only one adult patient with PPTID. Although PPTID was first described in 1993, it was not recognized by the WHO until the 2000 classification and represents only 1% of primary central nervous system tumors. Prognosis falls somewhere between that of a pineocytoma and pi...
Does PT/PTT elevation due to severe vitamin K deficiency protect against thrombosis?
Yes, most of us think that vitamin K deficiency increases the risk for bleeding rather than protecting against VTE.
In what situations would immunotherapy alone be appropriate for non-metastatic NSCLC?
Based on our current SOC treatment paradigms for patients who don't have contraindications to definitive treatment options, my short answer would be no. However, few caveats to that no as always. Few examples where I think this would be an appropriate approach based on currently available data. Poor...
How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?
Thanks for the question. Highly complicated case. Few things matter here. First, what platform is used for ctDNA testing (whether tumor informed or not), and second whether this is T4 or T3 disease. It would be unusual to have high CEA but negative ctDNA in a true minimal residual disease (MRD). For...