Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a bladder cancer with rectal invasion with radiation?
In general, it may be difficult to achieve durable control with chemoRT alone for such a locally advanced T4 cancer such as this, and the patient may be better served with neoadjuvant chemo, restaging, and cystectomy, if this is feasible. If he is not a candidate/refuses cystectomy, would treat the ...
How do you manage refractory hyponatremia in patients on active therapy in small cell lung cancer?
The classic teaching is that if this is a paraneoplastic SIADH then treat the underlying cancer. If hyponatremia is worsening despite treatment, it might herald progression. I have used tolvaptan in the past as bridge but without effective treatment, this is likely not going to be very effective. Of...
Would you prefer nivolumab/ipilimumab combination over single agent pembrolizumab for a metachronous low volume MSI-H, metastatic colon cancer, with KRAS mutation?
To date, I don't think there are any single negative or positive predictive markers of response to immunotherapy in dMMR/MSI-High.The ones identified retrospectively on subset analyses include KRAS as you mentioned Other studies with BRAF, Or liver metastatic disease Elderly However, my take/experi...
How do you initially treat patients with cN3 cM0 esophageal cancer?
This is an extremely heterogenous group and requires expert multidisciplinary review to generate an individualized plan. In fact, we discussed several patients with N3 disease -- very extensive but technically locoregional lymphadenopathy -- at our Disease Management Team meeting yesterday morning.O...
For a patient requiring adjuvant endocrine therapy for localized breast cancer, would you use fulvestrant if they were intolerant to both aromatase inhibitor and tamoxifen?
I think you may run into coverage issues since fulvestrant is not approved for the treatment of early breast cancer. For patients who don't tolerate AI or tamoxifen, I normally try Fareston (toremifene). I have a small handful of patients in my panel that have tolerated that when they haven't tolera...
Would you consider trastuzumab deruxtecan as next line of therapy for patients with ERBB2 mutation positive, stage IIIB NSCLC, who progress within 6 months of chemo- radiation?
Yes, I would consider trastuzumab deruxtecan as the next line of therapy for patients with ERBB2 mutation-positive, stage IIIB NSCLC, who progress within 6 months of chemo-radiation. We typically use recurrence within one year as the time frame between completion of chemo-radiation and recurrence fo...
For patients with NSCLC on osimertinib who progress, would you continue osimertinib when moving onto chemotherapy for 2nd line therapy?
It all depends if we have systemic vs non systemic acquired resistance. You can continue osimertinib if you have slow progression or oligomets can be treated with local therapy like radiation. Sometimes you can increase the dose to 160mg if only CNS progression and asymptomatic. In case of systemic ...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
Would you offer trastuzumab + pertuzumab alone for patients with early stage, HER2+ breast cancer for whom TCHP is clearly indicated but who adamantly refuse any cytotoxic therapy?
Yes, I would use this regimen pre-operatively, since our general process is to use TCHP (or THP) and de-escalate as needed for toxicity for patients with clinical stage T2 or N1 or higher. Here, the "de-escalation" is immediate due to strong patient preference (which of course should be documented)....
How would you incorporate ctDNA to follow up a patient status post surgical resection of the primary colon adenocarcinoma and omental deposits after 6 months of FOLFOX?
This is an excellent question. Can ctDNA add to the treatment algorithm for patients with peritoneal carcinomatosis where imaging frequently underestimates extent of disease? We are virtually in a data-free zone, but one study (Baumgartner, Ann Surg Oncol. 2018) showed that for 59 patients (mainly w...