Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients who develop oligometastatic renal cell carcinoma amenable to local therapies (i.e. ablation, radiation therapy, or surgery), how do you integrate systemic therapy, if at all?
With full disclosure that the answer to this question is in the relm of a data free zone, for patients with oligometastatic disease not on systemic therapy, the answer is of course dependent upon site of disease i.e. CNS vs bone vs liver etc. That said if the solitary site of disease is managed with...
For patients with malignant mesothelioma who achieve macroscopic complete resection, what factors would lead you to consider adjuvant chemotherapy or radiation?
As chemotherapy has been the only treatment shown to improve survival in patients with pleural mesothelioma, I consider it a component of treatment for all patients undergoing surgical resection, since all patients are left with microscopic residual disease (with rare exceptions). I would therefore ...
How do you assess and encourage adherence to adjuvant hormonal therapy in early stage breast cancer patients?
Adherence is important to maximize the benefits of adjuvant therapy. Unfortunately studies that measure adherence (pill counts, bottle monitors, prescription records) suggest that many (as many as 40%) of patients discontinue therapy or take <85% of planned doses within the first 5 years. I ask open...
Would you use immune checkpoint inhibitors in patients with well-compensated liver cirrhosis?
There are essentially no good data describing the safety and efficacy of immune checkpoint inhibitors in patients with compromised organ function. The issue is complex, in that altered liver function will change protein binding of the drugs, potentially alter catabolism etc. Autoimmune hepatitis has...
How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?
MRI can provide useful results about tumor stage before and after re-operative chemoradiation. If tumors show a good response to chemoradiation this is a good prognostic sign. For tumors that are initially very large, another reason to do an MRI after chemoradiaiton is to see if the tumor is surgica...
How do you manage severe cytarabine syndrome in AML patients, manifesting as severe hypotension, fevers, rash, and myalgias?
The cytarabine syndrome is a well-described (Castleberry et al. (1981) Medical and Pediatric Oncology 9:257) syndrome mediated by pro-inflammatory cytokines that are associated with fever, hypotension, rash, and often renal failure. In my experience, its most severe manifestations occur when a patie...
Do you see a role for adjuvant sunitinib after resected RCC?
The role of VEGF-R inhibitors as adjuvant therapy in RCC is an evolving field. As you point out, ASSURE was negative but S-TRAC was positive. Each study has to be interpreted on it own while also trying to reconcile the different results. S-TRAC was different in that it was clear cell only, a higher...
How do you decide what to use for 2nd line treatment of liver-predominant metastatic neuroendocrine tumor that has progressed on a somatostatin analog?
Following progression on an SSA, there are a number of options and they differ depending on primary site and whether or not the tumor is functional (ie. secreting a hormone that causes symtoms of hormone excess. I will outline some scenarios below:1) For patients with non-functional liver-predominan...
How would you approach the management of a patient with oligometastatic NSCLC characterized by a LUL mass and a solitary adrenal metastasis, assuming a good performance status?
Induction chemotherapy (platinum-doublet x3 cycles) followed by lobectomy, mediastinal lymph node dissection, and adrenalectomy if no progression after induction chemotherapy.Reference: Gomez DR et al, Lancet Oncology 2016
What is the role of platinum agents in the treatment of metastatic breast cancer in patients with BRCA mutations?
The TNT study compared taxanes versus carboplatin in triple negative breast cancer and did not show a difference in response rate. However, amongst BRCA germline mutation carriers there was a significantly higher response rate amongst women with BRCA mutations. Therefore, platinums are good options ...