Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat a patient with synchronous locally advanced lung and head and neck cancers?
This is obviously a very difficult and challenging clinical situation. Most people have a very difficult time undergoing simultaneous treatment to both areas. Typically, I have started with induction systemic therapy. This is especially useful for larynx and hypopharynx cancer patients. This provide...
When do you use neoadjuvant endocrine therapy for postmenopausal women with ER positive early stage breast cancer?
I think that neo-adjuvant endocrine therapy is an excellent option particularly for post-menopausal women with strongly ER/PR + cancers who are marginal candidates for breast conservation. I will generally consider for those women who don't have any characteristics that I think would require chemoth...
How do you approach subsequent treatment in patients with unresectable hepatocellular carcinoma who have progressed on first line sorafenib?
For patients with widespread bony metastases from prostate cancer, do you ever consider treating with beta-emitters such as Samarium-153 or Strontium-89 over Radium-223?
I use radium 223 in all patients unless thier performance staus is poor ECOG-2 or they have significant visceral disease. In those cases it may difficult to get authorization for Radium 223. In terms Cost effectiveness there is data now from the ALSYMPCA trial updates that patient's who received Rad...
Is there any role for re-challenge with enzalutamide or abiraterone after prior failure in metastatic castrate-resistant prostate cancer?
Returning to a therapy on which a patient with mCRPC had previously progressed can be done with docetaxel (Bracarda et al, Future Oncol. 2015;11(22):3083-90; Di Lorenzo et al, Medicine (Baltimore). 2016;95(14):e2754), where a patient may derive clinical benefit to a re-challenge. Typically, the pati...
How do you approach a patient with Stage I node negative ER+ invasive ductal carcinoma s/p lumpectomy who has an intermediate Oncotype?
Intermdiate scores always require a long discussion with the patient - this is definitely a case with no one answer. The potential benefit of ANY chemotherapy is quite small. Some patients may accept chemo for that small benefit, others easily defer. I haven't used AC alone in many years. When I do ...
How do you decide on the modality of consolidative treatment after a CR in primary CNS lymphoma patients treated with a high-dose methotrexate regimen?
Unless there are contraindications to autologous transplant I favor consolidation with autologous transplant. The long term complications of whole brain XRT include significant neurocognitive deficits. These approaches are rough equal with regards to efficacy.
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
In which patients would you recommend extending adjuvant AI-based therapy beyond 5 years?
Several keenly awaited trials were presented or published last year. The MA17R looked at extending AI for 5 more years after nearly 10 years of anti-estrogen therapy (5 of which was with an AI). It showed a significant benefit in preventing contra-lateral breast cancers. These are patients who toler...
Do you routinely send Oncotype Dx on ER positive tumors with node positive disease?
I believe that the intrinsic biology of the tumor is more important than the lymph node status in determining prognosis and potential chemotherapy benefit. Given this, I do use molecular assays for node positive disease with caution. Based on a 2010 Lancet Oncology paper in which tissue blocks from ...