Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you use Oncotype for adjuvant colon cancer treatment decisions?
Oncotype is an RNA expression profile validated in multiple prospective phase 3 trials. It is mainly validated for stage II colon cancer, but data for stage III also exist from NSABP C0-7. Since the stage II data is prognostic, not predictive it does not give the benefit of treatment (though data fr...
How do you approach the development of an LGL clone in a NHL patient actively getting therapy?
Most likely, i would monitor the clone and continue with the ongoing treatment plan. This is assuming the size of the clone was relatively small and that the patient was asymptomic in this regard. The development of a T-cell or NK-cell clone isnt necessarily indicative of a separate disease, does no...
Would you recommend anti-hormonal therapy in a patient with DCIS that is ER/PR positive between 1-9%?
In general terms, I consider tumors with ER and PR expression <10% as hormone receptor negative. Our analysis of outcomes for these patients at our institution suggest thy do just as well (or as poorly) as those with ER 0% and PR 0%. Therefore, I do not recommend the use of endocrine therapy of pati...
How do you approach choice of systemic chemotherapy for a young and otherwise healthy patient with HER2 negative esophogeal adenocarcinoma?
I really think that, in the US context, FOLFOX is the standard and preferred regimen. It is now the accepted regimen in US single-arm and randomized studies. Although there are differing toxicities, I would argue that cisplatin 60-80 mg/m2 (which is the dose in published regimens) represents cruel a...
If a patient with a germ cell tumor has such an event thrombotic events on BEP, is it safe to re-challenge with BEP therapy?
If a patient has an acute thrombotic event, the patient would subsequently be treated with an anticoagulant. These events are most commonly venous thrombi or thromboembolisms but arterial thrombotic events also occur. If the patient is appropriately anticoagulated based on the specifics of the event...
What would be your choice and duration of adjuvant therapy for a perforated MSI-H stage II (T4N0) colon cancer?
There are no data of which I am aware which directly address this situation. Although patients with stage II MSI-H tumors generally have an extremely favorable prognosis, the perforation is worrisome. I would not be opposed to giving six months of adjuvant FOLFOX in this setting as long as the patie...
Is a CLL FISH panel sufficient to aid in treatment decisions in CLL or is p53 sequence analysis also needed?
At a minimum, patients should undergo IGHV mutation analysis as well as testing for deletion of 11q and 17p prior to treatment initiation. However, testing for a TP53 mutation is ideal. While many patients with TP53 mutations will have a concomitant deletion 17p, this is not always the case. Given t...
How would you treat metastatic squamous esophageal carcinoma that is HER2 negative?
In general we would not check HER2 status in squamous cell tumors of the esophagus. I think FOLFOX would be a reasonable first line regimen. Others would be cisplatin with 5FU. There is no standard of care first line regimen. Another reasonable option would be carboplatin with paclitaxel.
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
Do you ever start immunotherapy along with WBRT in patients with PDL1 >50% metastatic NSCLC with significant visceral tumor burden in addition to symptomatic brain mets?
The general rule in the era of chemotherapy has been to hold concurrent therapy in the context of palliative radiation--in particular whole brain radiation--due to added side effects. These principles have shifted to some extent in the context of targeted therapies and checkpoint inhibitors as exper...