Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you counsel patients on the risk of dementia following androgen deprivation therapy for prostate cancer?
No, I generally do not counsel men about this risk. The two studies from the same investigator use a data warehouse search algorithm that may not be accurate enough to fully characterize who gets Alzheimer's disease or may not be able to correct for confounding factors that may be different between ...
How to you treat patients with germ cell tumors that progress during treatment with first-line platinum-based chemotherapy (i.e. platinum-refractory disease)?
This is extremely uncommon and a common mistake is to label someone as cisplatin refractory who really isn't. I would have to see the pattern of markers over the course of treatment and be assured that sanctuary sites have been ruled out prior to formally declaring someone as cisplatin refractory. T...
How would you treat a patient with metastatic, MSI high, small bowel adenocarcinoma in the frontline setting and after first progression?
This is a really interesting question. If you prefer a more standard approach, I would recommend FOLFOX (I have used bevacizumab in some patients with this cancer, but there isn't great evidence I know of to support use). However, in an MSI-H patient, trying anti-PD-1 therapy sooner rather than late...
How would you treat a patient with metastatic colon adenocarcinoma with a HER2+ tumor who has progressed despite standard 5-FU containing regimens?
Assuming the patient has progressed on standard treatments for mCRC including oxaliplatin and irinotecan-containing regimens with the appropriate biologics, I would consider HER2 directed therapy. I generally prefer that to be on clinical trials such as MyPathway or MATCH or similar trials. Outside ...
Do you ever consider referring fit patients with NSCLC and oligometastatic disease isolated to the pleura for extrapleural pneumonectomy?
I do not believe that there is a role for EPP in NSCLC patients with pleural nodules. The morbidity of the surgery is quite high, and the chance of cure is minimal. This is not a situation for which the term oligometastatic disease is truly appropriate. On the other hand, if the patient has pain fro...
How do you approach patients with low ER positive (1 - 9%) breast cancer?
The EBCTCG meta-analysis on adjuvant tamoxifen found benefit with tamoxifen use across all subgroups of ER expression, including the low expressors (1-9%). The absolute benefit of tamoxifen may not be significantly high. In my practice, I do offer anti-estrogen therapy in such a setting, but have a ...
How do you approach the management of borderline resectable pancreatic cancer in patients with superior mesenteric artery vs vein abutment ?
This is an area where treatment paradigms are in flux. If there is no vascular abutment our usual policy is resection followed by adjuvant treatment. With the augmented response rates being seen with FOLFOXIRI and gemcitabine + nab paclitaxel there is a better chance that tumor shrinkage off of vasc...
What treatment options would you consider for a patient with an ECOG PS of 0 with metastatic non-uterine leiomyosarcoma who has progressed on all standard systemic therapies including anthracycline, gemcitabine, taxane, vinorelbine, pazopanib, temozolomide, and trabectidin?
The correct answer is a phase 1 clinical trial, or perhaps compassionate use immunotherapy.
How do you counsel men with prostate cancer on the cardiovascular risks of androgen deprivation therapy?
This is a complex issue and depends on the specific setting (concurrent with XRT), the risk of the patient, and the specific CV risks of that patient. In the metastatic setting, there is almost never a contraindication to hormonal therapy given that prostate cancer is the likely cause of death in th...
Do you routinely perform molecular profiling for potentially actionable targets in patients with advanced pancreatic cancer?
In our practice, we reserve the use of molecular broad NGS testing to our patients with metastatic disease, usually at time of first progression. Unfortunately not too many patients will have an actionable mutation, as the most common ones would be in KRAS and TP53. CDKN2A is the most frequently ina...