Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What initial systemic approach will you recommend for metastatic pMMR HER2-positive esophageal/GEJ/gastric adenocarcinoma with PDL1 of 0?
FOLFOX-trastuzumab-pembrolizumab is consistent with the 2023 Immunotherapy and Targeted Therapy for Advanced Gastroesophageal Cancer: ASCO Guideline (Shah et al., PMID 36603169). In KEYNOTE-811, a response benefit was shown by adding pembrolizumab to trastuzumab plus chemotherapy (Janjigian et al., ...
How do you manage a symptomatic primary breast tumor in a patient with metastatic disease?
It’s much harder to treat patients palliatively than to cure. The art of palliation generally requires weighing the acute and subacute toxicities of alternative treatments much more heavily and chronic toxicities less than we do for potentially curative care. It also requires assessing whether patie...
For a patient with ICI toxicity who is resistant to the use of high-dose steroids, are there scenarios where you would consider the use of first-line conventional synthetic DMARD in place of steroids?
Loaded question — I think we need a reframing of ICI-toxicity, much of the ICI side effects are just an autoimmune reaction in a specific organ. High doses of steroids are used if there is a true risk for organ damage (like when you have acute ANCA vasculitis, lupus nephritis, etc.). So if a patient...
Would you ever consider adjuvant chemotherapy for a patient with rectal cancer treated with RAPIDO total neoadjuvant therapy after positive PNI was found on the surgery?
The patient should have received adequate systemic therapy per the RAPIDO trial; therefore, additional chemotherapy will not add any further benefit.
Does delay to the time of lumpectomy impact your decision to omit radiation?
There seem to be two issues to consider in this situation. One is whether patients undergoing neoadjuvant endocrine therapy, then lumpectomy without RT, have an acceptable local recurrence rate. The only study I know of directly addressing this issue was presented at a poster session of the 2017 San...
What are your top takeaways in Neuro Oncology from ASCO 2025?
Aizer et al., JCO 2025 - A multi-instituitional Brigham Dana-Farber-led trial randomized 196 patients with 5-20 brain metastases to stereotactic radiosurgery (SRS) or hippocampal avoidance whole brain radiotherapy (HA-WBRT). Patients treated on the SRS arm had significantly less symptom burden, wit...
How would you treat node positive (pN+) prostate cancer with undetectable post-op PSA after radical prostatectomy and pelvic LND?
The short answer is, YES I would, in general, recommend treatment. I also respectfully disagree that ADT monotherapy is the standard of care. It is an option of course, but rarely performed given it is non-curative and the data to support its use is of minimal relevance today.Some key points of reas...
What would you choose as second-line therapy in patients with ER/PR-positive, HER2-negative metastatic breast cancer progressing on first-line CDK 4/6 inhibitor/AI combination?
While we don't have direct comparative data, my own preference is fulvestrant both because in treatment-naive patients it appears better than NSAI (20% improvement in PFS in FALCON), and because the toxicity profile favors fulvestrant over everolimus/exemestane.
If an asymptomatic patient requires a delay up to a week before starting chemotherapy for Stage III lung cancer, do you also push back the radiation start date?
Typically, the reason for B12 and folate prior to chemotherapy is related to the drug that will be used, pemetrexed. Giving the premedication reduces hematologic and gastrointestinal toxicity to tolerable levels. One week typically will not make a difference and I would usually wait to start. Howeve...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...