Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Can patients on steroids receive immunotherapy?
In general, it is acceptable to be on the equivalent of 10 mg/day of prednisone (at least this is what has been the cutoff used in most of the trials). Also, patients on replacement doses (presumably of hydrocortisone) for adrenal insufficiency are, of course, also proper treatment candidates for ch...
Would you feel comfortable giving a HER2+ breast cancer patient her next cycle of TCHP (Taxotere + carboplatin + Herceptin + Perjeta) on day 17 of the previous cycle?
No. I usually delay chemo but never give chemo a week prior to the scheduled time. I can try a day prior. I'm worried about unnecessary toxicity in such a setting. Remember, adjuvant or neoadjuvant therapy is given to optimize the cure. You don't want to create lasting toxicity or place a patient at...
How would you manage a patient with low risk prostate cancer on active surveillance who develops high risk features but absolutely refuses a repeat biopsy?
In the setting of a suspicious mpMRI lesion, we start by acknowledging the patient's likely negative experience with their transrectal biopsy. We ask if they are referring to the one where they were rolled on their side, had a probe inserted in their rectum, and heard a bunch of loud CLICKs. We empa...
What adjuvant therapy would be recommended for node positive gastric adenocarcinoma s/p gastrectomy, in a patient who did not receive neoadjuvant therapy?
The 4 studies that provide guidance for adjuvant treatment are chemotherapy only (ACTS-GC and CLASSIC with 1 year of S-1 and Capeox respectively)chemoradiation (US INT 116 for bolus 5-FU/leucovorin before and after chemoradiation with 5-FU) and chemotherapy with or without chemoradiation (ARTIST stu...
Do you routinely offer adjuvant chemotherapy to patients with extrahepatic cholangiocarcinoma after R0 resection?
When do you consider re-starting treatment for a patient with relapsed myeloma?
Do you start anti-myeloma therapy when patients have progressive disease (25% increase in paraprotein or new or worsening myeloma bone disease) or clinical relapse (CRAB criteria, hyperviscosity, new plasmacytoma)? The goal is to pull the trigger right before clinical relapse. How is this done in th...
Do you have a cut-off for bilirubin for treatment of patients with poorly differentiated NSCLC with good PS and liver dysfunction due to mets?
The management of patients with extensive liver mets resulting in elevated bilirubin depends upon the clinical scenario. The question posed indicates this patient has a good performance status and a lung cancer histology of "poorly differentiated NSCLC". The factors that I would consider when treati...
Do you send Oncotype or Mammaprint as a predictive tool for patients with high grade (3/3) lymph node negative ER+ breast cancers?
No it doesn't overrule. The key question is whether you would predicate chemotherapy use according to the genomic test estimates of prognosis with ET alone (oncotype, mammaprint, prosigna, EPclin etc).
How do you choose a dose of 5-FU during chemo-radiation for a patient with rectal cancer who is dialysis dependent?
5FU is not cleared by the renal excretion and does not require dose modification. I would tend to use the doses in the NSABP R-03 trial, 225 mg/m2/day continuously. Other published doses or bogus schedules may be equally used without dose modification. However capecitabine is cleared renally and sho...
For triple positive metastatic breast cancer, do you sequence or simultaneously use hormonal therapy along with chemotherapy?
There is little evidence to support concurrent administration of endocrine therapy with chemotherapy or chemotherapy plus anti-HER2 therapy, in metastatic breast cancer. Sequential use of endocrine therapy after completing a course of chemotherapy/anti-HER2 therapy is a reasonable alternative that m...