Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When treating a patient with multiple myeloma with bortezomib, how do you decide between subcutaneous vs intravenous dosing?
Due to the markedly increased risk of of peripheral neuropathy, the standard of care worldwide is to utilize subcutaneous bortezomib. There really is no medical indication to prefer IV over SQ. The issue of weekly versus biweekly bortezomib is controversial. The FDA indication is for biweekly on day...
Would you consider aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?
In general, no. The reason is that the many squamous cell carcinomas are a manifestation of immune dysfunction. Historically, when all the treatments were chemo-based, immunity would be if anything, temporarily worsened. Then, even in people in CR, immunity wasn't always restored. For example, patie...
Is there a role or data to support the use of Capecitabine with radiation to the breast/axilla in a metastatic ER positive breast cancer in the palliative setting?
I have occasionally administered capceitabine concurrent with radiation as a radiosenitizing agent in patients with unresectable chest wall recurrences with reasonably good tolerance. When administered together, I limit the capecitabine to a dose similar to that used in patients receiving concurrent...
How do you decide which tyrosine kinase inhibitor (sunitinib, pazopanib, cabozantinib) to use in the first-line setting for newly diagnosed metastatic RCC?
The choice of agents for the initial treatment of metatstatic RCCa has become more complex with the recent evidence and approvals in this disease. For newly Dx good prognosisi pts I choose either Sunitinib or Pazopanib as there is yet no evidence of something being superior. For intermediate and poo...
What is the best strategy after initial treatment with hypomethylating agents for high grade myelodysplatic syndromes, mainly for responders who became transfusion independent?
The hypomethylating agents (HMA’s, 5-azacitidine & decitabine) have important disease modifying properties in addition to relieving cytopenias for patients with high-risk MDS. They decrease the risk of progression to leukemia and improve overall survival. The randomized phase III Aza-001 study dem...
How would you treat a diffuse CNS myeloid sarcoma (aka chloroma/granulocytic sarcoma) without evidence of blood or bone marrow involvement?
Isolated myeloid sarcoma is a very rare condition effecting perhaps 1% of all pts with AML, so any therapeutic recommendations are merely educated guesses. Probably the best approach is some combination of systemic and local therapy (see MD Anderson report Leukemia 1&:1100, 2003) since many of these...
What is your adjuvant treatment approach to patients with strongly hormone-receptor positive breast cancer who have minimal response to neoadjuvant chemotherapy?
Many patients with strongly hormone receptor-positive tumors, including lobular cancers, may not respond to chemotherapy either clinically or by pathological response. In these patients, lack of response may not correlate with a worse long-term outcome to the same extent that it would in triple nega...
How do you talk to patients about clinical trials?
I try to incorporate the clinical trial idea into the standard of care recommendation/discussion at the time of initial treatment decision making. After making a standard of care rx recommendation, I tell patients that my recommendation is based upon this treatment being the winner of a prior trial ...
Is there any form of liquid biopsy that can detect ER and Her 2 expression for metastatic breast cancer?
Yes. The Circulating Tumor Cell Assay is able to detect ER and HER2 expression. But it has not been validated in prospective studies. I do not recommend using it for this purpose as we just do not know the sensitivity and specificity of such an assay. We have previously written a commentary about on...
Do you use oral etoposide in combination with carboplatin for small cell lung cancer, in light of the national shortage of IV etoposide?
Our preferred treatment for extensive SCLC is a platinum compound + IV etoposide. However with the national shortage, and our preference to "save" IV etoposide for metastatic germ cell tumors, we would use a platinum compound + irinotecan which is equivalent albeit with more G.I. toxicity. Another e...