Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you ever consider alternate dosing strategies for hormone directed therapy in breast cancer patients who cannot tolerate these drugs despite other supportive care strategies?
When a patient has not tolerated other supportive care strategies I often tell patients to stop for a week and see if the symptoms resolve. Then have them re-start very slowly - sometimes a 1/2 a pill every other day for a week then gradually up to a pill a day. There is no data that supports this a...
Do you treat patients with metastatic renal cell carcinoma who progress on first-line TKI with single agent nivolumab or the combination of nivolumab plus ipilimumab?
This is an interesting and timely question that clinicians will face. Although data for nivo monotherapy in the front line is sparse, it is clear to me that the combo has more activity than nivo monotherapy based on ORR and CR rate. It also carries more toxicity. One approach would be to start patie...
Are there subsets of patient in which you would choose chemotherapy+pembrolizumab vs pembrolizumab monotherapy in metastatic NSCLC?
My take on what to do in the >50% PD-L1 patients from an unapologetic cross-trial comparison of KEYNOTE-024 and the 50% subgroup of KEYNOTE-189: mPFS: 10.3 in KN24, 9.4 in KN189PFS at 12 months: 48% in KN24, 45% in KN189OS at12 months: 70% in KN24, 73% in KN189 Thus, I think chemo does not add anyth...
Is there a situation where you would use a purine analogue in combination with rituximab for the frontline line treatment of normal variant Hairy Cell Leukemia?
This is an excellent question, and I was assisted in this answer by Drs. @Dr. First Last and @Dr. First Last who are both hairy cell leukemia experts since there is really not a lot of trial data to guide this answer. There is limited data for the addition of rituximab in the frontline setting in vH...
For patients with high-risk metastatic castration-sensitive prostate cancer who have completed upfront ADT + docetaxel, would you consider starting abiraterone or enzalutamide in addition to ADT while the disease is still castration-sensitive?
No. In patients with castration-sensitive disease on ADT who have completed six cycles of docetaxel as per the CHAARTED data (Sweeney et al. NEJM 2015), there is no good evidence that adding abiraterone after docetaxel while still castration-sensitive is warranted. Abiraterone has potential harm and...
What would be your choice of endocrine therapy (if any) for a premenopausal woman with an ER positive 2nd DCIS in ipsilateral breast who has completed 5 years of tamoxifen after lumpectomy of 1st DCIS?
The original DCIS was 10 years ago and Tamoxifen was given to prevent a local recurrence and a new primary. We have data that tamoxifen can have beneficial effects for at least 5 years after discontinuation. GIven that this is the second primary the first thing would be to check her genetics. THat m...
Can the CDK 4/6 inhibitors be used in patients with metastatic breast cancer to the bone marrow?
CDK 4/6 inhibitors do cause cytopenias, especially neutropenia in patients with metastatic breast cancer. Palbociclib and ribociclib cause neutropenia more frequently, and more frequently severely than abemaciclib. This would be my primary concern in treating patients with breast cancer metastasis t...
How would you treat metastatic malignant peripheral nerve sheath tumor in a patient who received adjuvant Adriamycin ( 240 mg/m2) 10 years ago for breast cancer?
Ifosfamide+Etoposide has activity in MPNST and could be considered in a patient with prior doxorubicin. In general MPNST is treated as other metastatic soft tissue sarcomas. There is still the possibility of giving a doxorubicin containing regimen such as doxorubicin+olaratumab for a couple cycles a...
Is there any evidence for efficacy of using a PARP inhibitor in metastatic triple negative breast cancer who progressed on platinum therapy with BRCA-2 variant of unknown clinical significance on molecular testing?
The main recent PARPi trials (OlympiAD, Embraca) enrolled women with known or suspected pathogenic germline mutations so the efficacy in true VUS patients is not known. There are efforts to try and predict the effect of VUS mutations on BRCA function (Woods et al Genomic Med 2016), but we don't know...
Is there a role for any non-cisplatin based adjuvant therapy or radiotherapy (in absence of platinum sensitizer) for muscle-invasive, node-negative bladder cancer after radical cystectomy?
This is a very clinically relevant question that we often wrestle with the optimal management. In the adjuvant space, multiple investigators have looked at alternative adjuvant chemotherapy regimens for patients after cystectomy and deemed cisplatin-ineligible. The most ideal would be carboplatin-ba...