Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In Stage I-II primary mediastinal B-cell lymphoma (PMBL), bulky or non-bulky, is post-chemotherapy radiotherapy still standard in patients with a complete response to CHOP-R chemotherapy?
Primary mediastinal B-cell lymphoma (PMBCL) is a rare subtype of DLBCL. It is a clinicopathologic entity by WHO criteria (which makes it occasionally difficult to conclusively diagnose). The typical patient is young, female, with a large, anterior mediastinal mass. The optimal therapy for PMBCL is c...
Should all GISTs be sequenced?
I believe that any GIST that is going to be treated with a TKI should be sequenced. The mutational response to TKIs are now well documented. 10% of GISTs are wild type and do not respond to Gleevec or Sutent. In addition, certain mutations like D842V in PDGF are also not druggable.
In what situations would you consider starting zoledronic acid in an adjuvant setting for a woman with T2N0 hormone positive breast cancer?
Adjuvant bisphosphonates should be considered in older, postmenopausal women or in younger, premenopausal women who are on ovarian suppression. I would check a baseline DEXA scan in this particular woman, and if she has osteopenia or osteoporosis, I would start her on a bisphosphonate. She would be ...
Do you ever offer neoadjuvant endocrine therapy to pre-menopausal women?
I do not tend to offer neoadjuvant endocrine therapy to premenopausal women, unless it is in a clinical trial setting. There is limited data available but 6 months of ovarian suppression plus an aromatase inhibitor was found to be more effective in reducing tumor size than tamoxifen (clinical partia...
When should patients with metastatic melanoma be referred for treatment at an academic center?
In order to move the field forward and advance care for metastatic melanoma patients, all patients with a good performance status should be considered for clinical trials. That said, trials need to be carefully designed and appropriate pre-clinical studies should be done as there now are quite an ab...
Is there a benefit to adjuvant chemotherapy for patients with a solitary liver metastasis from previously treated colorectal cancer?
I know this question was asked last year, but for the record: Mark makes some great points above, but I respectfully disagree on using irinotecan in the post-met/micrometastatic setting. I don't feel the Ychou study provides enough support for this practice since there was no significant improvement...
How would you manage a patient with EGFR mutant adenocarcinoma of the lung on erlotinib with a single site of disease progression, but otherwise well-controlled disease?
This is a point of controversy. There are multiple reasonable options to consider for such a patient: Keep going with tarceva and follow the lesion carefully. The NCCN guidelines actually acknowledge this approach for asymptomatic disease. Use SRS or some other locally ablative approach to destro...
When is the best time to start denosumab in men with metastatic prostate cancer?
The data supporting the use of bone modifying agents (BMAs) such as denosumab or zoledronic acid are certainly the most solid for men with castration-resistant prostate cancer (i.e. progresion of disease through inital LHRH analog therapy) (Saad, JNCI 2004; 94: 1458–68; Fizzazi Lancet Oncol 2011; 37...
What mutational testing is considered the standard of care for NSCLC?
The easy answer to this question is that the only molecular alterations for which we have matched FDA-approved drugs for those specific indications are EGFR and ALK, so the standard of care would be to test only for EGFR and ALK. However, over the past 2-3 years, we came to appreciate that several o...
Do you treat rectosigmoid/upper rectal cancers with neoadjuvant chemoradiation?
The 12-year update to the phase III pre-op RT Dutch rectal trial found a local control benefit with RT regardless of location (VanGijn et al., Lancet Oncol. 2011; 12(6):575-82.). In the Dutch update, tumor location was analyzed as a continuous variable. This is different from the every 5 cm cut-offs...