Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When, if ever, do you add platinum to neoadjuvant chemotherapy in patients with triple negative breast cancer?
There are 2 ongoing randomized trials that will address this question. One is in the adjuvant setting and the other in patients with residual disease after neoadjuvant therapy. Use of platinum is currently not in any guidelines, even for mutation carriers.
After chemotherapy for early and locally advanced breast cancer, how long do you advise women to wait before attempting to conceive?
This is an area with little data to guide recommendtions. Population databases have NOT found an increased risk of recurrence in patients who conceive after diagnosis and treatment - if anything those who conceive do better (this form of bias has been called the healthy mother effect). Timing of con...
What is the duration of AI that you use in men with hormone receptor-positive early stage breast cancer?
There are no prospectively conducted studies in men with breast cancer. We extrapolate data from adjuvant breast cancer trials with tamoxifen which were conducted in women. Based on some retrospective data, tamoxifen is deemed to be the safe and effective option in men. However, in metastatic breast...
What duration of androgen deprivation therapy do you use for patients with pN+ prostate cancer undergoing upfront adjuvant RT after a radical prostatectomy and pelvic lymph node dissection?
As @Dr. First Last mentioned, the Messing randomized trial (ECOG 3886) showed that lifelong ADT (vs. observation) improved overall survival in patients with pN+ prostate cancer after radical prostatectomy. This trial provides the only level 1 evidence for this patient population. Therefore, ADT shou...
Are there any subgroups of patients with advanced/metastatic NSCLC for whom you are using PD-1 inhibitors in the first-line setting, either alone or in combination with platinum-based chemotherapy?
With the advent of the 024 study pitting single agent Pembrolizumab vs standard chemotherapy in treatment-naive, advanced NSCLC showing a PFS and OS benefit in individuals whose tumors harbor high levels of PDL1 expression (> 50%), one can certainly make a strong case for testing all patients for PD...
Is there a role for atezolizumab as a first-line agent for metastatic urothelial carcinomas?
The first question is whether the patient can tolerate cisplatin-based chemotherapy and whether or not they received (neoadjuvant or adjuvant) cisplatin-based chemotherapy within at least 1 year (if received peri-operative cisplatin-based therapy, it is a longer discussion regarding re-challenge tha...
For lung cancer patients who experience grade 3/4 toxicity from a PD-1 inhibitor necessitating cessation of therapy, but whose tumor has responded to the treatment, do you consider restarting PD-1 inhibitor therapy at the time when they progress again?
This is a highly challenging question that all of us face now with increasing frequency given the ever-widening utilization of checkpoint inhibitors. A decision as to resuming an anti-PD-1/PD-L1 agent in a patient who suffered a serious immune-mediated side effect clearly requires great judgment and...
For the first-line treatment of metastatic lung adenocarcinoma without a targetable driver mutation, do you routinely add bevacizumab to the chemotherapy backbone in the absence of a contraindication to the drug?
That is a really good question. In my practice, I typically will use carboplatin plus pemetrexed for 4-6 cycles followed by maintenance pemetrexed. The addition of bevacizumab consistently improves response rates when added to chemotherapy, so if I have a patient that is symptomatic from local disea...
How do you treat patients with small cell lung cancer that is primarily refractory to platinum/etoposide (i.e. disease that continues to progress despite first-line chemotherapy?)
Unfortunately I have rarely seen second-line therapy provide meaningful benefit in patients with previously treated small cell lung cancer and have little enthusiasm for treating these patients outside of a clinical trial. Recently reported data for therapies such as nivolumab+Ipilimumab and rovalpi...
What adjuvant chemotherapy regimen is most appropriate for a patient with local recurrence several years after surgery and ddAC-T for localized breast cancer?
In this situation, it is preferable to use a chemotherapy regimen that has been shown to be effective in the adjuvant setting. For a patient who has already received ddAC-T, my choice would be TC (docetaxel/cyclophosphamide), or even CMF. The role of chemotherapy for locoregional recurrence is still...