Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does rituximab + lenalidomide have a role in advanced follicular lymphoma?
There has been much interest in replacing traditional chemo-immunotherapy (generally R-bendamustine, R-CHOP or R-CVP) with noncytotoxic therapy such as rituximab plus lenalidomide in patients with previously untreated advanced stage follicular lymphoma. Studies in relapsed/refractory patients have s...
Do you use anticonvulsant prophylaxis in patients with multiple CNS metastases absent a history of seizures?
If there’s never been a seizure, I do not recommend anticonvulsant prophylaxis.
How would you approach adjuvant therapy for a finding of carcinosarcoma in a prostatectomy specimen?
Pure "carcinosarcoma" a biphasic neoplasm with both epithelial adenocarcinoma with second component which is a clearly recognizable type of sarcoma is of course extremely rare, thus my comments must be considered in the data free zone from which they eminate. Both local recurrence and systemic failu...
What is your preferred second-line agent for treatment of metastatic urothelial carcinoma?
Great question, currently only atezolizumab and nivolumab are FDA-approved in this setting. Overall, there are several parameters to take into account (by the way, I suggest a recent review on ASCO "value-based care", which is creating a framework and parameters for the evaluation of cancer drugs ut...
How do you approach molecular testing in patients with gastro-esophageal cancers?
Her2 is certainly more of a binary situation. Tumors that are Her2 positive (defined as IHC 3+ or IHC 2+ and FISH +ve) benefit from trastuzumab + chemotherapy, while there are no data to support it for tumors that are Her2 negative (IHC 0/1 or IHC 2+ and FISH -ve). So, Her2 positive tumors should ab...
How do you choose between single agent versus combination checkpoint inhibitors for BRAF Wildtype metastatic melanoma?
In a randomized study, the combination of nivolumab and ipilimumab has demonstrated superior progression free survival compared to nivolumab alone in patients with melanoma. However, grade 3/4 AEs were 55% in patients treated with the combination versus 16.3% among patients treated with nivolumab al...
Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?
There is not a clearly defined role for adjuvant sorafenib following locoregional therapy for HCC. The two main prospective randomimzed trials that inform this recommendation are:- The SPACE trial (Lencioni et al, J Hepatol 2016) -- no improvement in TTP when DEB-TACE was followed by sorafenib vs pl...
What is your approach to pre-menopausal or male breast cancer patients on adjuvant tamoxifen who develop a DVT, in the absence of other risk factors for thromboembolic disease?
The treatment of male breast cancer is similar to premenopausal female breast cancer with respect to endocrine therapy. The 2 acceptable options for treatment are, therefore, either Tamoxifen or Aromatase Inhibitors + GNRH agonists. In patients with DVT, I would favor switching from Tamoxifen to AI+...
Is there evidence of clinical benefit to proceeding with partial pleurectomy / decortication over palliative chemotherapy with BSC (pleurex catheter, pleurodesis) in a patient with mesothelioma who is not a candidate for extra-pleural pneumectomy?
There is no compelling evidence here. The only randomized data are from the UK MesoVATS trial, reported in 2014, showed that patients with pleural mesothelioma randomized to video-assisted thoracoscopic partial pleurectomy/decortication had no difference in 1 year survival compared to those who unde...
When would you consider local ablative therapy (e.g. SBRT, surgery) for patients with oligometastatic non small cell lung cancer on immunotherapy?
Definitely would treat this exactly as I do for EGFR or ALK-targeted therapy. If the patient is doing well, and most sites of disease continue to be controlled but one is progressing I would consider local ablative therapy. That being said, I just had a patient doing well with a CR on ipi-nivo for ...