Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is ALND required in all patient with clinically positive axillary nodes?
The role of surgical management of the axilla is clearly an area that is evolving, especially in light of effective systemic therapies for breast cancer and the lack of convincing evidence of a survival benefit. The potential functional morbidity associated with an axillary dissection is not small s...
Is there a role for prophylactic cranial irradiation in patients with NSCLC?
The question of PCI for stage III NSCLC has now been asked twice in the modern era. The abstracts of both of these studies are below. They both show that although PCI reduces the incidence of brain metastasis, it does not improve survival. And when there is the fatigue and neurotoxicity associated w...
What approach would you take for patients with metastatic castration-resistant prostate cancer with marked PSA response (undetectable) on docetaxel, but radiographic progression in bone metastases?
As a first step I would confirm that the patient has truly had radiographic progression of his bone metastases. Prostate cancer can often demonstrate what has been termed a "healing flare" following response to systemic therapy, and radiographic progression in bone requires a follow up bone scan (us...
In a premenopausal woman with low risk, early stage HR-positive breast cancer who is unable to discontinue a strong CYP2D6 inhibitor, do you use still utilize tamoxifen versus an AI with ovarian suppression?
CYP2D6 enzymes metabolize tamoxifen to the active metabolite endoxifene. There are variants alleles of the the 2D6 enzyme such that depending on the inheritance of one or two variant alleles one makes less endoxifene. Testing for variant alleles is clinically available, however, the results of studi...
Is there a degree of osteoporosis (based on T-score) that would prohibit you from the utilization of an AI in a strong HR+ early stage breast cancer?
Tamoxifen is often underutilized in many patients who otherwise have a narrow benefit/risk ratio from an AI. It is more preserving and more tolerated, and should be used more readily in the majority of patients with lower risk disease. Using a sequence of tamoxifen and an AI is also very reasonable ...
How would you advise a woman who had a full axillary lymph node dissection on the risk of lymphedema with mountain climbing?
Well, this is obviously a question with no evidence based answer. Overal, the risk of lymphedema after axillary LN dissection is around 20-25%. Most likely these patients will receive regional LN radiation (due to positive LN's) and the risk will increase to 25-30% (Warren et al). Other risk factors...
How early have you been able to detect a response with CAR-T in patients with relapsed DLBCL?
Responses to CAR-T cell therapy is generally very rapid. As seen in the ZUMA-1 trial median time to response was 30 days. Having said that there are patients in whom continued responses can be seen as late as 5-6 months post therapy, so patient who are in a PR at 1 month, it may be reasonable to jus...
If you decide to discontinue TKI after prolonged molecular remission in CML, how often would you follow the BCR/ABL after discontinuation?
The NCCN has updated the guidelines and included specific and detailed criteria for TKI discontinuation. Per the NCCN guidelines: "Monthly molecular monitoring for one year, then every 6 weeks for the second year, and every 12 weeks thereafter (indefinitely) is recommended for patients who remain in...
Do you use gene expression profiling for premenopausal women with hormone receptor positive breast cancer with 1-3 positive lymph nodes?
I do use gene expression profiling in premenopausal women with 1-3 nodes positive.Premenopausal women represented 33% of all women in MINDACT (NEJM, 2016) (about 2100, a substantial number) and more than half of these premenopausal women had low genomic risk (and therefore a median 5 year distant di...
Would you use 6 months (instead of 12 months) of trastuzumab for locally advanced Her-2 positive breast cancer patients?
I would not recommend 6 months of maintenance trastuzumab for higher risk patients, such as one that received neoadjuvant therapy. The PERSEPHONE trial1 had as its strength its large size and sufficient number of events for a conclusion regarding the population tested (and the diversity of regimens ...