Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you differentiate primary from secondary iron overload?
Medical history helps- transfusion history, chronic hemolytic anemias, ESRD on HD, and inflammatory conditions increase the risk of secondary iron. In my practice, I use MRI to help distinguish between primary and secondary iron overload. In primary iron overload, the iron will only be seen in the l...
Do you recommend ADT or other systemic therapy in patients with rising PSA after prostatectomy and salvage RT and PSMA scan negative for metastatic disease?
Generally, I do not recommend systemic therapy for such patients. If doing so, it would be intermittent ADT (alone) for 6-or 9-month cycles. The EMBARK study will hopefully address this important question.
In which scenarios would you utilize sacituzumab govitecan earlier than third line in the treatment of metastatic TNBC?
To date, we do not have a head-to-head comparison of sacituzumab govitecan prior to the 3rd line setting and insurance approval for sacituzumab govitecan prior to 3rd can be a barrier. However, I consider it under the following circumstances: The patient has significant pre-existing neuropathy. Many...
How do you decide between 1st line PARPi or immunotherapy in a patient with metastatic gBRCA mutated TNBC?
In a patient with a gBRCAm that is PDL1+, I generally consider chemotherapy + checkpoint inhibition in the first line setting given the known survival benefit upfront, and since it is unknown if this benefit with chemotherapy + immunotherapy would be seen in the later line setting. We do have data t...
When do you consider HER2-targeting antibody drug conjugates in the first line setting for metastatic HER2 positive, ER negative breast cancer?
This question cannot be answered for any specific situation with a high degree of reliability without a controlled clinical trial. In my opinion, there could be situations in which I would predict a favorable benefit/risk ratio to the use of T-DXd in first line as opposed to standard taxane + trastu...
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...
How would you manage the side effects/toxicities (e.g., pain, swelling, erythema) of adjuvant EBRT to the ear for cutaneous SCC?
I have had a few patients experience acute pain in the ear canal, probably from inflammation, wet desquamation, and bacterial overgrowth. Ciprodex Otic drops x 7-10 days have been helpful.
What is the preferred neoadjuvant/adjuvant chemotherapy regimen for HPV-associated nasopharyngeal cancer?
Let me give more context: Had an interesting conversation with a med onc colleague regarding neoadjuvant or adjuvant gem/cis for HPV-associated NPC. I personally make a distinction between EBV-associated NPC and HPV-associated NPC. My interpretation of the data is that the benefit is only/mainly for...
In p16-positive oropharyngeal squamous cell carcinoma, when induction therapy is considered before definitive chemoradiation, how do you choose between a traditional TPF regimen and carboplatin/paclitaxel/pembrolizumab?
Sequential therapy, as defined by induction chemotherapy followed by chemoradiation, is generally reserved for patients at high risk for recurrent or metastatic disease. The published randomized data offers no improvement in survival with TPF followed by CRT versus CRT. Thus, such an approach can be...
For unresectable-appearing BRAF V600E papillary thyroid cancer involving the trachea and carotid artery, is neoadjuvant targeted therapy a viable path to surgery, or is definitive radiation the better option?
If the tumor is considered unresectable due to carotid encasement, as is likely in this case, then neoadjuvant targeted therapies should not be considered. Multikinase inhibitors (i.e., lenvatinib) or targeted therapies (dabrafenib and trametinib) will not produce great enough responses to make the ...