Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider concurrent chemoRT for unresectable bladder adenocarcinoma?
The simple answer is YES. If unresectable then follow the established treatment paradigm of maximal TURBT followed by ChemoRT. Platinum based regimens are typically the standard with good evidence for alternative schedules such as 5FU/mitomycin or Gemcitabine (low dose). This is s potentially curati...
How do you handle the situation where a curative-intent patient unexpectedly passes away while under treatment?
As many of the patients we treat are older and have numerous co-morbidities, this is not that rare an occurrence. Of course, we would presume to avoid treating patients with curative intent if it is readily apparent that their life span will be short due to other non-malignant illness. That said, I ...
For NSCLC patients with limited diagnostic tissue that is insufficient for genetic testing, do you offer repeat biopsy (of accessible site), blood based testing, or both to evaluate for actionable driver mutations?
If a patient has insufficient tissue for molecular testing, I will immediately send a liquid biopsy while simultaneously setting up a repeat biopsy. Our blood-based testing returns within 5-7 days. If a driver mutation is found on liquid biopsy, I will cancel the repeat tissue biopsy. If no driver m...
How would you approach patients with EGFR mutation positive (exon 19) NSCLC who rapidly progress on front line EGFR inhibition with first generation TKI at first imaging?
This is a difficult challenging situation. I usually repeat tissue biopsy or at least order a liquid bx, confirm that in fact they did have the EGFR mutation and assess for the T790M. I do consider switching to osimertinib if they have the T790M and this was not the EGFR TKI they were on. However ch...
Which chemotherapy regimen do you prefer for concurrent treatment with radiation therapy for anal squamous cell carcinoma?
When you have a highly successful treatment such as radiation with concurrent mitomycin and 5-FU in a rare disease such as epidermoid carcinoma of the anal canal, it is extremely difficult to improve outcomes by improving the chemotherapeutic/radiosensitizing effect. The recurrence rate is so low no...
Are there any situations where you would you add docetaxel to gemcitabine + capecitabine for locally advanced unresectable pancreatic cancer?
Do you recommend adjuvant chemotherapy for local relapse of invasive lobular carcinoma after surgical resection?
This one often depends on the nature of local relapse and whether relapse occurred on ET. The CALOR trial as flawed as it was suggested that chemotherapy helps in the "repeat adjuvant" setting, however that benefit appeared mostly in HR-disease. That said, lobular cancers are not chemotherapy insens...
When do you consider it too late after surgery to offer adjuvant chemotherapy for colon adenocarcinoma?
Retrospective studies suggest that there are diminishing returns for adjuvant chemotherapy beginning 2-3 months after surgical resection. This is almost certainly a continuous variable, so I don't interpret this data to mean that one should never consider adjuvant chemotherapy after that time point....
Should NSCLC with positive cervical nodes be managed with definitive chemoradiation?
The AJCC staging system in conjunction with the IASLC lymph node map is quite clear on this issue. Cervical lymph nodes are non-regional and in the TNM classification are noted as M1b or stage IV. From a practical standpoint though, one should consider the number and location of the lymph nodes in q...
Do you recommend starting sorafenib at a reduced dose and titrating up in patients with advanced hepatocellular carcinoma?
Yes, I do. In our recent, large retrospective analysis of nearly 5,000 patients with HCC, we noted that starting at a lower dose of sorafenib and titrating up as tolerated (1) did not adversely affect OS and (2) resulted in less toxicity and cost to patients (Reiss et al, JCO). In this setting, I th...