Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you routinely use risk assessment scores (e.g., the Khorana score) to assess the risk of venous thromboembolism and consideration of prophylactic anticoagulation in ambulatory cancer patients undergoing / about to undergo treatment?
How would you treat a patient with locally advanced HR+ breast cancer with contralateral axillary lymph node involvement?
Locally advanced breast cancers, particularly those with substantial nodal burden, can cause aberrant lymphatic drainage patterns, including to the contralateral side. For this reason, in a patient with LABC and contralateral nodal involvement, we look for a contralateral primary and distant disease...
How would you treat an elderly female with metastatic HR+,HER2- breast cancer on endocrine therapy who now has progressive bone only disease?
If it was minimal bone only progression, I would consider adding a CDK 4/6 to fulvestrant, albeit there is no data for doing so. I agree with checking for PI3K although I think this class of drugs is likely to be difficult to tolerate for someone described as elderly. Finally we still have the optio...
How would you approach a premenopausal woman with HR+, HER2- metastatic breast and a PIK3CA mutation?
Ovarian ablation of some sort + AI + CDK 4/6 inhibitor. At relapse, consider fulvestrant + alpelisib.
Does your recommendation for ADT change in an elderly patient with dementia and high risk prostate cancer?
Thank you for this question. There have been publications that have shown the association of ADT and cognitive decline. Probably one of the most robust studies was published in 2017 (Nead et al., PMID 27737437) in which the effect of ADT on dementia risk was assessed using propensity score-matched m...
Is there a role for high-dose chemotherapy in a patient with metastatic choriocarcinoma with brain-only recurrence within two years of diagnosis after prior treatment with first and second line chemotherapy (BEP x4 and VIP x3)?
This is the type of patient who would likely benefit from direct or indirect consultation with a high volume center, which most such centers are happy to provide. It is unlikely that his CNS therapy to date, which may or may not provide long term CNS control, will not likely permanently prevent syst...
Would you offer EGFR inhibitors to a patient with metastatic lung adenocarcinoma EGFR L858R mutation and concomitant NRAS mutation both on blood based testing?
This of course should be a rare event. Indeed, out of the hundreds of EGFR mutation positive patients I have seen, I have only encountered one case of concurrent KRAS G12C mutation and no concurrent NRAS mutation. The classic teaching is that KRAS mutations and EGFR mutations are mutually exclusive,...
How do you treat anaplastic multiple myeloma?
I would defer to a hematopathologist for a more detailed discussion of the morphological features, but in general anaplastic myeloma is characterized by cells that are so pleomorphic and poorly differentiated as to bear little resemblance to plasma cells. Because of this, the diagnosis can sometimes...
Are you more inclined to use neoadjuvant endocrine therapy over neoadjuvant chemotherapy or upfront surgery for your ER+HER2- breast cancer patients during the COVID19 pandemic?
For clinically low risk early stage node negative tumors that are strongly ER/PR+ HER2-, neoadjuvant endocrine therapy with follow up is reasonable during this phase of the pandemic. ASCO has released some guidance to help with these questions. Ultimately, we will need to work together to conserve m...
What is your preferred neoadjuvant chemotherapy (FOLFIRINOX vs gemcitabine/nab-paclitaxel) and duration for a resectable T2N1 pancreatic adenocarcinoma in a fit patient whose surgery has been cancelled due to COVID-19 risk in the hospital?
We treat resectable pancreatic patients with neoadjuvant therapy regardless. In a fit patient, we will recommend starting with FOLFIRINOX chemotherapy. Restaging scans should be fine every 2 months. We could consider therapy for 4-6 months.