Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant chemotherapy for a patient with ER/PR (+), HER2(-) breast cancer less than 5mm in size with a high Oncotype score?
I don't get genomic tests in T1aN0 tumors, in fact many times the tissue is insufficient. These patients were not reflected in the studies validating these assays, and existing data suggest they have excellent prognosis.
Among patients with anal SCC, is it reasonable to replace 5-FU with capecitabine when delivering definitive chemoradiotherapy with concurrent mitomycin C?
Yes, capecitabine can be substituted for infusional 5-FU in this setting. The NCCN guidelines include the capecitabine/mitomycin + RT regimen.
When do you refer patients for acupuncture for AI associated joint pain?
We recently presented the results of S1200, a phase III trial comparing 12 weeks of true acupuncture to sham (fake) acupuncture to a wait list control group (no intervention), and found that acupuncture improved pain more than the other 2 groups and the effects persisted over 24 weeks. Duloxitine, c...
In what circumstances would you repeat bio markers (ER, PR, HER2) in a patient with breast cancer who has residual disease after neo-adjuvant chemotherapy?
We typically do not repeat biomarkers in patients with residual disease after neoadjuvant chemotherapy as there are not clear guidelines or supportive data on how to use this information for treatment decisions. Treatment recommendations are based on initial biopsy results as long as the specimen is...
Would you use single agent adjuvant HER2 directed therapy for patients with low risk HER2+ breast cancer who are not candidates for chemotherapy?
There are no data regarding single agent trastuzumab as adjuvant therapy, and the existing studies (FinHER, SOLD) suggest that much of the benefit occurs during the chemotherapy phase. The "after chemo" efforts (HERA, N9831) appear inferior. So I would try to incorporate the chemotherapy component, ...
Would you ever consider giving treatment break to patients with triple negative metastatic breast cancer who responded to chemotherapy?
Unfortunately, the incurable (at least for now) nature of metastatic breast cancer means that we must balance efficacy with quality of life concerns. I frequently give patients brief breaks to allow them to enjoy trips, weddings, holidays when possible. However, I don't routinely do stop and go chem...
How do you manage adult brainstem lesions in the absence of a tissue diagnosis?
I would: Discuss with the neuro-radiologist and obtain another imaging study(e.g. PET or MR perfusion) that could support the MRI diagnosis of high grade glioma. Have a thorough discussion at a multi-disciplinary neuro-oncology tumor board to make sure surgical biopsy is unsafe and there is consens...
How would you treat a fit, newly diagnosed, high-risk multiple myeloma patient with multiple poor risk factors and circulating plasma cells?
So...on most iFISH, we see a deletion of p53, but we don't know about the mutation. Similarly on iFISH we see trisomies and tetrasomies of 1q23, often CKS1B, but not genetic amplification. Finally circulating plasma cells are often missed when less than 5% even at large academic centers, and while t...
Would you use alternative management in a chronic phase CML with a 3 way translocation between chromosome 9, 22 and 7?
Variant Philadelphia chromosome translocations that involve a third or fourth chromosome in addition to chromosomes 9 and 22 are seen in around 5% of patients with CML. They are considered simple translocations if involved chromosome 22 in addition to a chromosome other than 9, or complex if involve...
In what situations do you obtain both a pelvic MRI and EUS for rectal cancer staging and treatment planning?
I'm not sure that T2N1 is boderline - preop CRT is still a standard of care for node positive disease. Generally, thin slice (3mm or less) MRI with external (if available) or internal coil is the preferred staging modality for patients with newly diagnosed rectal cancer. Utilize the T2 images and c...