Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you use an alternative dosing regimen for CDK4/6 inhibitor in patient with benign ethnic leukopenia?
It is known that patients of african descent have a lower white blood counts (Ethnic Neutropenia). Despite the lower WBC and Neutrophil count, there is no evidence of increased risk of infection. In this setting i usually do not lower the dose, but set a lower cut-point for dose change, or only chan...
Do you pursue testing for ERBB2 mutations in patients with metastatic breast cancer who are clinically HER2-negative by IHC and FISH?
I generally will consider NGS in women with progressive TNBC or progressive ER positive, Her2 negative MBC that has progressed through at least 3-4 hormonal therapies and/or chemotherapies. I find that about 5-10% of these women have mutations in the tyrosine kinase domain of Her2 (a bit higher than...
How would you treat a patient with a small (<0.5 cm) node negative, grade 3 BRCA1 mutated triple negative breast cancer?
In the recently published POSH trial by Copson et al (Lancet Oncology), the investigators examined outcomes in a cohort of women age 40 or younger newly diagnosed with breast cancer. In the overall cohort of 2733 women, 12% had BRCA mutations. After a median follow-up of 8.2 years, there was no sign...
How would you treat a post menopausal woman with newly diagnosed PR positive, ER negative and Her 2 negative metastatic breast cancer with germ-line BRCA2 mutation?
Based on current evidence the outcome of patients with germline BRCA 1 or 2 mutation who developed breast cancer is similar to patients with breast cancer who do not carry germline BRCA mutations. I would use similar judgement in regards to decision for different systemic therapy as I would if the p...
When treating a patient with multiple myeloma with bortezomib, how do you decide between subcutaneous vs intravenous dosing?
Due to the markedly increased risk of of peripheral neuropathy, the standard of care worldwide is to utilize subcutaneous bortezomib. There really is no medical indication to prefer IV over SQ. The issue of weekly versus biweekly bortezomib is controversial. The FDA indication is for biweekly on day...
Would you consider aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?
In general, no. The reason is that the many squamous cell carcinomas are a manifestation of immune dysfunction. Historically, when all the treatments were chemo-based, immunity would be if anything, temporarily worsened. Then, even in people in CR, immunity wasn't always restored. For example, patie...
Is there a role or data to support the use of Capecitabine with radiation to the breast/axilla in a metastatic ER positive breast cancer in the palliative setting?
I have occasionally administered capceitabine concurrent with radiation as a radiosenitizing agent in patients with unresectable chest wall recurrences with reasonably good tolerance. When administered together, I limit the capecitabine to a dose similar to that used in patients receiving concurrent...
How do you decide which tyrosine kinase inhibitor (sunitinib, pazopanib, cabozantinib) to use in the first-line setting for newly diagnosed metastatic RCC?
The choice of agents for the initial treatment of metatstatic RCCa has become more complex with the recent evidence and approvals in this disease. For newly Dx good prognosisi pts I choose either Sunitinib or Pazopanib as there is yet no evidence of something being superior. For intermediate and poo...
What is the best strategy after initial treatment with hypomethylating agents for high grade myelodysplatic syndromes, mainly for responders who became transfusion independent?
The hypomethylating agents (HMA’s, 5-azacitidine & decitabine) have important disease modifying properties in addition to relieving cytopenias for patients with high-risk MDS. They decrease the risk of progression to leukemia and improve overall survival. The randomized phase III Aza-001 study dem...
How would you treat a diffuse CNS myeloid sarcoma (aka chloroma/granulocytic sarcoma) without evidence of blood or bone marrow involvement?
Myeloid sarcoma prognosis is not good and treatment need high dose ARA-C based chemo As induction. Would consider IT chemo would consider Omaha as well. Patient will need after CR CS radiation inculded in the conditioning regimen to consolidate with Myeloablative transplant. HLA and donor activation...