Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you monitor ovarian function in high risk, premenopausal breast cancer patients receiving adjuvant ovarian suppression?
Great question. Extremely clinically relevant. Here's the problem with 'medical oophorectomy': ABCSG-12 showed that OFS+AI in premenopausal women who were overweight had a 50% increased risk for disease recurrence. SOFT trial sub-study, SOFT-EST, showed that one in three women on OFS+AI have subopti...
For patients with metastatic NSCLC with sensitizing EGFR mutations who progress on first line TKI therapy who do not have evidence of T790M mutation, do you add cetuximab (with afatinib) or bevacizumab (with erlotinib) at progression?
Treatment paradigms have altered considerably over the past two years for patients with EGFR mutations There are now three approved TKIs (afatinib, gefitinib, erlotinb) that all have demonstrated improved outcomes when compared to chemotherapy. In addition, the addition of bevacizumab to erlotinib i...
How do you treat leptomeningeal carcinomatosis in metastatic breast cancer?
LMD is a challenging clinical scenario. I will consider placement of Ommaya and IT MTX or cytarabine in select patients, generally limited systemic disease and good PS. If any evidence of bulky disease, will check CSF flow study prior to placement. Other options include systemic high dose methotrexa...
What is your preferred approach to a patient with newly diagnosed primary mediastinal B-cell lymphoma in the upfront setting?
I recommend DA-R-EPOCH in almost all patients. For the rare patients with stage 3-4 disease, I consider RCHOPx4 followed by ICE (unpublished data from Memorial Sloan Kettering).
For newly diagnosed BRAF mutated melanoma with brain metastases, do you prefer to start with targeted therapy or with immunotherapy?
Selection of systemic therapy, targeted therapy versus checkpoint immunotherapy, relies upon a comprehensive evaluation of patient's performance status, the number, size and location of brain metastases (BMs), neurological symptoms, and the extent of extracranial disease. 1. If the patient has poor ...
For patients who develop oligometastatic renal cell carcinoma amenable to local therapies (i.e. ablation, radiation therapy, or surgery), how do you integrate systemic therapy, if at all?
With full disclosure that the answer to this question is in the relm of a data free zone, for patients with oligometastatic disease not on systemic therapy, the answer is of course dependent upon site of disease i.e. CNS vs bone vs liver etc. That said if the solitary site of disease is managed with...
For patients with malignant mesothelioma who achieve macroscopic complete resection, what factors would lead you to consider adjuvant chemotherapy or radiation?
As chemotherapy has been the only treatment shown to improve survival in patients with pleural mesothelioma, I consider it a component of treatment for all patients undergoing surgical resection, since all patients are left with microscopic residual disease (with rare exceptions). I would therefore ...
How do you assess and encourage adherence to adjuvant hormonal therapy in early stage breast cancer patients?
Adherence is important to maximize the benefits of adjuvant therapy. Unfortunately studies that measure adherence (pill counts, bottle monitors, prescription records) suggest that many (as many as 40%) of patients discontinue therapy or take <85% of planned doses within the first 5 years. I ask open...
Would you use immune checkpoint inhibitors in patients with well-compensated liver cirrhosis?
There are essentially no good data describing the safety and efficacy of immune checkpoint inhibitors in patients with compromised organ function. The issue is complex, in that altered liver function will change protein binding of the drugs, potentially alter catabolism etc. Autoimmune hepatitis has...
How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?
MRI can provide useful results about tumor stage before and after re-operative chemoradiation. If tumors show a good response to chemoradiation this is a good prognostic sign. For tumors that are initially very large, another reason to do an MRI after chemoradiaiton is to see if the tumor is surgica...