Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For locally recurrent NSCLC after surgical resection but with subcentimeter ipsilateral nodules of indeterminate etiology, would you consider local therapy such as chemoradiation +/- durvalumab?
Time to relapse influences the treatment modality. Presuming relapse occurs at least a year or more after the initial surgery, we typically triage and re-evaluate if surgical resection is feasible again for local recurrence after prior resection. Since these are subcentimeter and of indeterminate et...
How would you approach treatment for cT4 stage IIIC colorectal cancer that is d-MMR and not amenable to surgery due to volume of disease?
As my more learned colleagues here suggest, an evidence-based approach if this is colon cancer, is to use chemotherapy alone, as we lack high-level data for immune checkpoint inhibitors in this scenario. If rectal cancer, then I think emerging data from MSKCC would suggest better response to concurr...
How do you treat localized prostate cancer with neuroendocrine differentiation?
Most hybrid or pure NEPC tumors lack PSMA expression as only 1/3 of metastatic NEPC tumors are PSMA PET+ and expression is typically very heterogeneous. For this reason, an FDG PET/CT would likely be a better staging test for this aggressive variant of prostate cancer. If this is also N0M0, RP is my...
How would you approach systemic therapy for a pre-menopausal woman with ER+/PR+/HER2 positive breast cancer who had a local recurrence 6 months after completing adjuvant TCH and a year of trastuzumab + tamoxifen?
This patient has high-risk disease. First point: Option 1: Since the cancer recurred 6 months from TCH, I think you can justify using TDM-1 and pertuzumab combination based on I-SPY 2 data (pCR achieved in 52% for women treated with TDM-1 and pertuzumab versus 22% for women treated with trastuzumab ...
How do you approach management of sickle cell patients who mistrust Western medicine and prefer naturopathic therapies?
With compassion and understanding, I would explain that the lifespan of patients with SCD in regions with access to Western medicine far exceeds that where the disease is most prevalent. Controlled clinical trials have proven the utility of hydroxyurea to alter beneficially the course of disease and...
Do you offer PARP inhibitor maintenance retreatment of platinum-sensitive, relapsed, high grade serous ovarian cancer in patients who had a complete response to their most recent platinum-based chemo?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, PARP inhibitors niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. These patients were not treated with prior PARP inhibitor therapy in th...
Outside of a clinical trial, what is your treatment of choice for metastatic melanoma of soft parts or clear cell sarcoma?
There are two distinct entities - CSS of soft-tissues, an extremity tumor with melanoma-like behavior and some anecdotal evidence of melanoma-specific therapy having some activity, e.g. checkpoint inhibitors. The other one is a CSS-like tumor of the GI tract. Both have EWSR1 rearrangement. The speci...
For which patients with resected NSCLC will you offer adjuvant atezolizumab after completion of cisplatin-based adjuvant chemotherapy?
The initial results of IMpower010 were presented by Dr. @Dr. First Last at ASCO 2021. This study demonstrated that adjuvant atezolizumab following surgical resection and adjuvant platinum based chemotherapy improved disease free survival in stage II-IIIA NSCLC patients with tumors with PDL1 expressi...
Would you consider surgical management of a TNBC primary after a patient has had radiographic resolution of oligometastatic disease?
Randomized studies have revealed no advantage with removal of primary; however, there is a growing body of evidence in other cancers for treating oligo-metastatic disease with curative intent. Breast cancer is not colon cancer, etc but I feel the concept is novel and in the era of highly effective s...
How long would you continue chemotherapy for resectable pancreatic cancer not amenable to surgery due to functional status or comorbidity?
I think it depends upon the severity of functional limitations and comorbidites. If the patient can tolerate systemic therapy, I would favor the use of radiotherapy after an initial trial of systemic therapy (duration purposefully vague as it would be dictated by tolerance). I’ve generally favored S...