Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage musculoskeletal pain in men receiving androgen deprivation therapy for non-metastatic prostate cancer?
This a very good question. Because bone pain can be a symptom of "benign" bone health issues without bone metastasis and because of the patient population demographics including risk factors, we obtain baseline bone health screening on most patients who must undergo Androgen Deprivation Therapy (ADT...
Which chemotherapy regimen would you choose for a female adolescent with favorable prognosis stage I-II Classical Hodgkin lymphoma, assuming the patient prefers not to do IFRT if the initial PET response is good?
How do you counsel premenopausal women with BRCA1 or BRCA2 mutations on the need for bilateral oopherectomy?
I typically mirror the NCCN guidelines in this area. For those with BRCA 1 mutations, I recommend RRBSO between age 35-40 after completion of childbearing. Because those with BRCA2 mutations typically have onset of ovarian cancer later, it is reasonable to delay until age 40-45. Counseling needs to ...
Do you use anti-PD-1/anti-PD-L1 therapies in lung cancer patients with a prior history of radiation pneumonitis?
I have used anti-PD-1 directed therapies in patients with a prior history of radiation pneumonitis. The history had excluded her from one clinical trial of these agents but not another that is also combining the anti-PD-1 directed therapy with a CTLA-4 agent. If someone is on steroids for a current...
How would you treat a cancer of undetermined primary site presenting as peritoneal carcinomatosis, with pathology suggesting intestinal or pancreatobiliary origin?
Assuming the rest of the work-up for unknown primary/GI primary is unremarkable, I would probably treat with FOLFOX. That would cover all the basis as well as possible. Depending on whether there is any organ involvement, I would also consider surgical evaluation for HIPEC (but only in the healthy, ...
What is your preferred first-line regimen for metastatic head and neck cancer?
5-FU/platinum/cetuximab is probably the textbook answer given that the study evaluating it, EXTREME represents the only positive phase III study ever in 1st line palliative head/neck treatment. However, in my practice, I reject it for human reasons. Simply put, the study was well named - the toxicit...
How do you manage patients with BRAF V600E-mutated metastatic melanoma who have a mixed radiographic response after several months of therapy with dabrafenib/trametinib?
Good question. This probaby means the patient will not be a long term survivor with targeted agents. The standard thing would be to switch to immunotherapy with either single agent anti PD1 or ipi+nivo combo. A more off base possibility would be to add Pembro to avoid rapid progression upon disconti...
When do you use high-dose IL-2 for metastatic renal cell carcinoma?
In general, as an academic investigator, I always prefer clinical trials over standard of care. However, most of the front line registration trials in mRCC with immunotherapy have recently completed accrual, with results currently awaited. I continue to offer the option of high dose Interleukin-2 (H...
How do you manage hematologic toxicities in solid tumor patients treated with immune checkpoint inhibitors?
While hematological side effects of checkpoint inhibitor therapy are uncommon, they do occur and certainly can run the gamut of any and all autoimmune manifestations of hematological disease. In my own experience I have seen patients with ITP on anti-PD1/PD-L1 therapy and others such as autoimmune h...
How do you monitor ovarian function in high risk, premenopausal breast cancer patients receiving adjuvant ovarian suppression?
Great question. Extremely clinically relevant. Here's the problem with 'medical oophorectomy': ABCSG-12 showed that OFS+AI in premenopausal women who were overweight had a 50% increased risk for disease recurrence. SOFT trial sub-study, SOFT-EST, showed that one in three women on OFS+AI have subopti...