Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Following presentation of the PRINCE at ASCO 2016, should we be offering intermittent docetaxel to patients with metastatic castration-resistant prostate cancer?
The simple answer is no, as this study was dramatically underpowered to reach any conclusion. A couple of issues:1. This trial was designed after the TAX 327 data showed q3 week therapy to be the standard of care. This trial allowed weekly therapy anyway, likely because some of their docs wanted to ...
Is there a role for VeriStrat testing in determining when to use an EGFR TKI in previously treated squamous cell NSCLC?
Excellent question and one that we have very little data to answer. Extrapolating from the second line PROSE trial (http://www.ncbi.nlm.nih.gov/pubmed/24831979), it seems reasonable to consider this test to help choose between TKI vs. chemotherapy as a third line option. That said, there are certain...
Should local consolidative therapy be offered to patients with oligometastatic NSCLC who do not progress after induction systemic therapy?
We were one of the three sites that accrued patients to this trial, and the benefits are compelling (a tripling of PFS, along with an OS benefit). Randomized phase II trials are usually not meant to be definitive, but these results are very informative for clinical practice. It's also important to n...
How should RT be combined with immunotherapy to generate an abscopal response?
This is a difficult question to answer because cancer "immunotherapy" is really a variety of heterogeneous therapeutic approaches. Nevertheless, I am aware of no consensus that specifies the optimal radiotherapy dose, fractionation, timing, or target, when used in conjunction with any specific form ...
When do you recommend a breast MRI for breast cancer surveillance?
MRI is a routine part of the work up (this would not be screening) for women presenting with axilary nodal disease and occult primary. In the era of MRI the incidence of so called occult primary has gone down becuase of higher sensitivity of MRI As far screening is concerned, it is approved for high...
What is the best way to discuss an early palliative care referral with a patient?
Patients (and providers) often struggle with the assumption that palliative care implies end of life care. While that is true in many cases, if you can overcome this false assumption, your patients can benefit. I often explain that palliative care like this: Palliative care serves as an extra set of...
Based on the data from the MA. 17R trial, would you re-start an AI in post-menopausal women who stopped therapy after 5 years?
There is no single answer here. The MA17R trial raises the question but doesn't directly address it. That said, the risk is of recurrence is ongoing so readdressing the benefits of additional therapy is quite reasonable. Important considerations include duration of time off therapy, side effects exp...
For male patients with invasive ductal carcinoma s/p unilateral mastectomy, subsequently found to have a BRCA mutation, should a prophylactic contralateral mastectomy be performed?
As is often the case in rare situations, there is no data to guide decisions. While men with breast cancer are more likey to have BRCA mutations, the risk of breast cancer in men with known mutations is substantially lower than in women with the same mutation. We have not routinely offered bilateral...
For castration-naive metastatic prostate cancer patients who you plan to treat with LHRH agonist monotherapy, how long do you treat with an anti-androgen therapy prior to and after initiating the LHRH-agonist?
I only use bicalutamide prior to starting LHRH agonist in patients with high risk of spinal cord compression or urinary obstruction. I will start bicalutamide for 7 days then start LHRH agonist therapy. In all other patients, I start LHRH agonist without combination with anti-androgen therapy.
Should ovarian suppression be recommended to premenopausal ER/PR positive patients?
The SOFT trial (https://www.ncbi.nlm.nih.gov/pubmed/25495490) found an improvement in DFS for combined ovarian suppression + AI compared to tamoxifen alone (the OA + Tam group was intermediate). While the overall results were positive, I think putting the results in practice requires looking at the ...