Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you prefer a chemo-radiation combination or chemotherapy followed by sequential radiation approach for early stage NK/T-cell lymphoma?
If SMILE regimen is used here (the preferred regimen for NK/Tcell lymphoma), radiotherapy should be delivered sequentially (not concurrent) due to normal tissue toxicity and poor tolerance.
What alternative therapies would you consider for a patient with metastatic castration-sensitive prostate cancer who declines GnRH analogues?
This situation is fairly uncommon, particularly in the metastatic setting, where these therapies are nearly universally effective and toxicities generally manageable. The alternatives of bicalutamide at high dose (150 mg/d) and enzalutamide also have toxicities and much less evidence to support thei...
How would you treat a premenopausal patient with ER/PR+, Her2 (-) metastatic breast cancer patient who progresses on tamoxifen?
I would give her maintenance fulvestrant high dose with palbociclib given she had progressed on tamoxifen (so combination anastrozole and fulvestrant maintenance will not be an ideal choice). While neither S0226 (first-line and few with acquired or innate resistance) and Paloma 3 (second line or fir...
What is your preferred regimen for triple positive breast cancer with bone only recurrence?
The primary options for triple positive MBC is whether to use antiestrogen approaches alone or with antiHER2 therapy, versus chemotherapy + HP. Indolent disease with bone-only involvement is the group for which antiestrogen-based approaches alone could be considered, although two randomized studies ...
What regimen would you choose for patients with breast cancer requiring adjuvant chemotherapy whose livelihoods depend on fine dexterity (such as a professional musician)?
The appropriate treatment depends on the clinical presentation of the breast cancer so that the risks/benefits of recurrence vs side effects are properly taken into account. A stage 3 TNBC would generally require a 3rd generation anthracycline/taxane regimen for optimal outcomes. A better approach w...
Would you consider maintenance therapy for patients who achieve complete response after palliative chemoradiation for metastatic distal esophageal adenocarcinoma?
There isn’t much evidence in this setting. I definitely consider chemotherapy and radiation in patients with small burden metastatic esophageal adenocarcinoma if they have significant dysphagia. Chemotherapy and radiation in the end is the most effective way to palliate dysphagia. I do however also ...
What dose regimen do you use when a women with inflammatory breast cancer is not responding to chemotherapy and needs radiation prior to surgery?
The data suggest pre op RT can convert some of these inoperable patients to surgery. I use comprehensive RT to preoperative dose of 50 Gy in 25 fractions in these patients
What is your approach to a low grade appendiceal mucinous neoplasm found incidentally at appendectomy?
If there is no high-grade component (adenocarcinoma), appendectomy is sufficient. There is no role for adjuvant therapy and no need for surveillance imaging in this setting. Low-grade appendiceal mucinous neoplasms with disseminated peritoneal adenomucinosis (pseudomyxoma peritonei) constitute an en...
How do you approach rising gastrin and chromogranin levels without radiographic evidence of disease in patients with gastrinoma that has been fully resected?
We see this scenario with some frequency - rising hormone or peptide levels in functional NETs without radiographic evidence of disease. My next step would be to get the new Ga68 DOTA TATE PET/CT - essentially a new generation octreoscan with high sensitivity and specificity. These scans often pick ...
When do you choose to give CyBorD over RVd in a newly diagnosed myeloma patient?
I only use VCd when patients are going to be inpatient for a while or the patient is unable to afford an IMiD. For patients with renal insufficiency, where time is of the essence, I recommend Velcade 1.3 mg/m2 SQ days 1,4,8,11 + dex 20 mg days 1,4,8,11 with Revlimid 5-15 mg in newly diagnosed MM. L...