Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with locally advanced rectal cancer who desire organ preservation and can tolerate fluoropyrimidine but not oxaliplatin, what is the appropriate treatment approach?
For patients with locally advanced rectal cancer who desire organ preservation and cannot tolerate oxaliplatin, the appropriate treatment approach would be neoadjuvant, long-course radiotherapy combined with fluoropyrimidine-based chemotherapy. After neoadjuvant treatment, patients are ev...
In a patient with local recurrence of breast cancer after mastectomy, how would you sequence adjuvant treatment after wide local resection?
Endocrine therapy can be given simultaneously with RT without increasing toxicity or decreasing effectiveness, as shown in a randomized French-Swiss trial (Azria et al., PMID 20138810). Toxicities from chemotherapy may be greater and its effectiveness reduced (at least for high-risk patients) when g...
Is the PROTEUS data enough to change your practice in the treatment of patients with high-risk localized or locally advanced prostate cancer?
The question asks if the results of PROTEUS would/should impact practice patterns...let us take a look: ADT is not recommended to be used with radical prostatectomy in prostate cancer by any guideline. Apalutamide or any ARPI are not recommended to be used with RP in prostate cancer in any guideline...
When, if ever, would you recommend risk reducing BSO in patients with moderate penetrance breast cancer germline mutations?
RAD51C, RAD51D, and BRIP1 are all associated with significant risks of ovarian cancer and are appropriate for consideration of prophylactic oophorectomy, albeit perhaps at a slightly later age than BRCA1 and BRCA2. ATM and PALB2 may be associated with ovarian cancer risks that are similar to that of...
What is the recommended follow-up/surveillance schedule following organ preservation treatment approach for cT1-2N0 rectal cancer?
Patients with stage I rectal cancer treated with organ preservation require close surveillance to rule out tumor regrowth and local recurrence that may be salvaged with radical surgery. The highest risk of recurrence is within 2 years after completion of neoadjuvant therapy and patients should be fo...
Would you consider use of PARP inhibitors in patients with metastatic breast cancer with moderate penetrance germline mutations such as CHEK2, ATM, RAD51?
In the Olaparib Expanded (TBCRC 048) study published by @Dr. First Last in JCO, there were no responses to olaparib in metastatic breast cancer with germline or somatic CHEK2 or ATM pathogenic variants (mutations). In contrast, responses were seen in metastatic breast cancer with PALB2 pathogenic va...
For which non-BRCA pathogenic germline variants, if any, might you consider recommending chemoprevention with SERM/AI?
The breast cancer prevention trials enrolled women with a risk of developing breast cancer equivalent to a 60-year old woman with no other risk factors. That is not a HIGH risk. Chemoprevention has been dramatically underused in both the truly high risk (if pathogenic mutation carriers) as well as t...
How do you counsel patients on the efficacy of breast cancer risk reduction strategies such as breast MRI surveillance or bilateral mastectomy for those considered high risk by polygenic risk score, pathogenic variants, and/or family history?
This is a difficult question with limited data to guide decisions. The ultimate goal of any screening effort is to identify disease earlier so that treatment is more effective (and hopefully less onerous) so that fewer patients die. We have good data that enhanced screening in high risk populations,...
Are CHEK2 mutations a contraindication for breast conservation therapy with lumpectomy + RT?
Among women with early-stage breast cancer and moderate penetrance breast cancer susceptibility genes, such as CHEK2, decisions about breast surgery are largely based upon personal preferences. According to data from large population-based studies, women with CHEK2 pathogenic variants have about a 2...
Should our selection for neoadjuvant chemotherapy in ovarian cancer patients change in light of COVID-19?
I see this as a two-pronged question where the response may vary based on the specific clinical situation, circumstances of the hospital, and status of the epidemic locally and regionally, along with available resources associated with the rapidly evolving COVID-19 pandemic. There is no question pri...