Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any data to quote possible benefit of endocrine therapy in an elderly woman with low risk breast cancer who is refusing primary surgical treatment?
Yes, there are primary neoadjuvant endocrine trial versus surgery in Cochrane review (Morgan et al., Surgery versus primary endocrine for operable primary breast cancer in elderly women (70 years old); Cochrane Database Syst Rev 2014;5:1-40). The randomized trials used tamoxifen. The bottom line is ...
Should durvalumab consolidation still be offered to Stage III NSCLC patients with PD-L1< 1%?
This is an extremely important question, but basing therapeutic decisions on this post-hoc, exploratory analysis is fraught with hazard. Still, the absence of OS benefit in this cohort (the HR heads in the wrong direction) gives me pause. For those with PD-L1 expression of 1% or higher, I enthusiast...
Is it acceptable defer or forgo biopsy and to start androgen deprivation therapy in an elderly, fragile patient with PSA in the 900s and evidence of bone metastases?
These questions come up regularly in practice. There seem to be two questions here.One is the acceptability of starting therapy for prostate cancer without biopsy confirmation. There is a small single institution retrospective evaluation and positive predictive value of PSA in diagnosing PCa. With a...
Are there any circumstances you would not recommend sentinel lymph node biopsy in a breast cancer patient?
It is clear that we are moving away from aggressive axillary surgery for patients with minimal axillary disease given that no survival or axillary recurrence benefit (ACOSOG Z11, AMAROS) and increased risks of functional morbidities have been identified with completion axillary dissection. Naturally...
When do you treat oligometastatic triple negative breast cancer aggressively?
This issue is complicated by the fact there is no standard definition for oligometastatic breast cancer. A study by Kobayashi et al. looked at a series of oligometastatic breast cancers defined as 1-2 organ sites involved with less than 5 metastases. Consolidative local therapy in chemo responsive p...
Is there a role for checkpoint inhibition in patients with advanced, high PD-L1 expressing, chemotherapy-refractory thymoma?
I agree with @Dr. First Last. For now, I would not treat thymoma patients with immune checkpoint inhibitors outside of a clinical study, based on the serious and frequent immune-related adverse events seen in this population as detailed above. There are several single agent chemotherapy options for ...
How do you manage a newly diagnosed locally advanced ER+/HER2- breast cancer with synchronous diagnosis of metastatic melanoma?
When dealing with two concurrent malignancies you need to look at the overall prognosis for both of them to determine the best course of action. If the melanoma was oligometastatic and resected to NED or had a complete durable response to immunotherapy then one could consider more aggressive curativ...
How do you manage elderly women with high-risk HER2 positive disease with baseline low ejection fraction?
Aside from avoiding use of an anthracycline, I would treat them with a chemotherapy regimen appropriate to their disease stage and overall medical condition - which may mean using a less intensive or shorter regimen than I would in a younger, fit patient with the same stage of HER2+ disease - plus t...
What systemic chemotherapy do you prefer with concurrent radiation therapy in the neoadjuvant setting for early stage rectal cancer?
In this setting, I always prefer capecitabine for the sake of patient convenience. If there is a reason I can't use it (e.g. renal insufficiency, poor compliance with oral medications), I opt for infusional 5-FU. I would only consider bolus 5-FU if the patient experienced coronary vasospasm with cap...
In view of possible equivalent efficacy of low dose abiraterone with food, has anyone had clinical experience offering low dose abiraterone to spare patients from financial toxicity of abiraterone?
The Szmulewitz study is a well done and robust pharmacokinetic study of low dose abiraterone with food. There is a well written commentary from Glenn Liu in the same issue of JCO.While the study does show pharmacokinetic equivalence, it is difficult to extrapolate comfortably to clinical equivalence...