Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach treating a patient with IgM-AL amyloidosis?
Good question. As pointed out, about 5% of lymphomas have a diagnosis of lymphoplasmacytic lymphoma (aka Waldenstroms) instead of a plasma cell dyscrasia. Small burdens of LPL can be difficult to detect unless specific testing is done (e.g., flow for clonal B cells) and intraclonal differentiation (...
What is your approach to treating relapsed subcutaneous panniculitis-like T-cell lymphoma?
Over the years the SPTL has been characterized better and the latest WHO lists it under PTCL with an α/β T-cell phenotype (SPTL-AB) and this has to be distinguished from primary cutaneous TCL with a γδ T-cell phenotype (PTCL-GD). Since they are so rare a workshop of the multidisciplinary EORTC Cutan...
For patients at high risk of breast cancer, do you recommend tomosynthesis over traditional two-view screening mammogram?
Currently, there are many radiology based clinical trials to compare the MRI vs US + 2D Mammo vs 3D Mammo. The STORM study (screening with tomosynthesis OR standard mammography) showed around 17% reduction of false positive, and 34% higher cancer detection rate in the 2D+3D combination arm. Among ca...
For a patient with metastatic castration-resistant prostate cancer to the bones with rising PSA but no evidence of radiographic or symptomatic progression, would you continue with the same treatment or change therapy based on biochemical progression?
This question emphasizes the importance of radiographic monitoring while on treatment for mCRPC. In a recent study from the PREVAIL trial of enzalutamide in chemo naive men with mCRPC, we found that radiographic progression occurred in about 1 out of 4 men (25%) without evidence of formal PSA progre...
How do you determine which HER-2 positive patients should receive neoadjuvant chemotherapy?
Chemotherapy in combination with anti-HER2 antibodies should be recommended to a patient with node positive, HER2 positive breast cancer. Since NSABP B18 and B27 showed no difference in long term outcomes between patients treated with neo-adjuvant vs. adjuvant chemotherapy, you can go either way. I ...
What neoadjuvant chemotherapy regimen would you choose for a young patient with HER2 positive breast cancer with reduced ejection fraction?
TCH or TCHP are both well-accepted non-anthracycline regimens; the benefit of pertuzumab is small so would omit unless the disease is very high risk. The issue of using any HER2-directed therapy in this setting depends upon the severity of the EF decrease (if minor may be able to manage with cardiol...
Would you use AR-V7 testing to decide second-line androgen receptor-axis-targeted therapy vs chemotherapy for patients who with metastatic castration-resistant prostate cancer?
In our PROPHECY multicenter AR-V7 validation trial, we compared the JHU AR-V7 CTC RNA test against the Epic/Genomic Sciences nuclear protein CTC AR-V7 test. Both tests, when positive, were strongly associated with lack of PSA response, short PFS, and short OS in men with mCRPC receiving abiraterone ...
How do you manage a locally advanced hormone receptor-positive invasive ductal carcinoma with neuroendocrine (small cell) features?
The first thing is to determine if the cancer has small cell features or if it is an extra pulmonary small cell cancer. If it is a true small cell cancer it will have the appearance of small cell in addition to staining for neuroendocrine markers (chromogranin and synaptophysin). Work up would inclu...
What is your approach to adjuvant HER-2 directed therapy in a patient who developed cardiotoxicity following neoadjuvant TC-HP?
Depending on the risk of the cancer and how bad the cardiotoxicity was, it may be worth trying to reinstitute HER2-directed therapy. Typically I hold HER2-directed therapy for a month at a time (until the EF gets to 50% or higher at which point I reinstitute) and involve a cardiologist familiar with...
Would you offer systemic therapy before or after resection of an axillary-only recurrence of triple negative breast cancer?
I would most likely consider the neoadjuvant approach. - of course, few things to consider prior to making a decision. 1. How long was the duration between the previous completion of therapy for her first breast cancer? And was previous therapy complete, or rather was incomplete therapy was given? 2...