Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For recurrent prostate cancer after definitive radiation, how do you guide patients between the various salvage options vs ADT?
This is a complex clinical situation and one needs to incorporate all available evidence regarding prior XRT details and PSA trajectory and imaging workup into the treatment decision. Below is the general strategy we use at Emory: For patients with rising PSA's post XRT, one should do a DRE, bone s...
In a patient with ER+/HER2- breast cancer, do you ever use Oncotype testing to assist in decision-making regarding adjuvant chemotherapy when the tumor size is less than 0.5 cm, or when there are positive lymph nodes?
The NSABP and other data that was approved for prognostication and for prediction of benefit with chemo excluded 5 mm or smaller tumors. In practice, oncologists would not offer chemo for ER positive and node negative tumors that are 5 mm or less in size . Thus, I would not do oncotype do testing. B...
Do you ever use bevacizumab in combination with standard radiation and temozolomide in the first-line setting for patients with glioblastoma?
Two clinical trials (AVAGLIO and RTOG 0825) used bevacizumab (Avastin) along with standard temozolomide and radiation therapy for newly diagnosed glioblastoma. While they did not see improved OS, they did see improved PFS. In an evaluation of AVAGLIO, for those patients who did not go on to receive ...
Do you routinely use tumor lysis prophylaxis when starting chemotherapy for germ cell tumors?
THere is not reason to use tumor lysis prophylaxis. Hydration of course is required for the cisplatin. I am not aware of anyone using allopurinol or other TLS approaches
When, if ever, do you add platinum to neoadjuvant chemotherapy in patients with triple negative breast cancer?
There are 2 ongoing randomized trials that will address this question. One is in the adjuvant setting and the other in patients with residual disease after neoadjuvant therapy. Use of platinum is currently not in any guidelines, even for mutation carriers.
After chemotherapy for early and locally advanced breast cancer, how long do you advise women to wait before attempting to conceive?
This is an area with little data to guide recommendtions. Population databases have NOT found an increased risk of recurrence in patients who conceive after diagnosis and treatment - if anything those who conceive do better (this form of bias has been called the healthy mother effect). Timing of con...
What is the duration of AI that you use in men with hormone receptor-positive early stage breast cancer?
There are no prospectively conducted studies in men with breast cancer. We extrapolate data from adjuvant breast cancer trials with tamoxifen which were conducted in women. Based on some retrospective data, tamoxifen is deemed to be the safe and effective option in men. However, in metastatic breast...
What duration of androgen deprivation therapy do you use for patients with pN+ prostate cancer undergoing upfront adjuvant RT after a radical prostatectomy and pelvic lymph node dissection?
As @Dr. First Last mentioned, the Messing randomized trial (ECOG 3886) showed that lifelong ADT (vs. observation) improved overall survival in patients with pN+ prostate cancer after radical prostatectomy. This trial provides the only level 1 evidence for this patient population. Therefore, ADT shou...
Are there any subgroups of patients with advanced/metastatic NSCLC for whom you are using PD-1 inhibitors in the first-line setting, either alone or in combination with platinum-based chemotherapy?
With the advent of the 024 study pitting single agent Pembrolizumab vs standard chemotherapy in treatment-naive, advanced NSCLC showing a PFS and OS benefit in individuals whose tumors harbor high levels of PDL1 expression (> 50%), one can certainly make a strong case for testing all patients for PD...
Is there a role for atezolizumab as a first-line agent for metastatic urothelial carcinomas?
The first question is whether the patient can tolerate cisplatin-based chemotherapy and whether or not they received (neoadjuvant or adjuvant) cisplatin-based chemotherapy within at least 1 year (if received peri-operative cisplatin-based therapy, it is a longer discussion regarding re-challenge tha...