Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer a mid-treatment transition from transtuzumab to TDM-1 for a patient already on 1 year of adjuvant trastuzumab who met criteria for adjuvant TDM-1 based on the KATHERINE trial?
The question is if the patient is er positive or negative. Most patients with residual disease are ER-positive or HER-2 positive. If the patient was ER-positive I would discuss switching vs. neratinib and go through the pros and cons of both.
Would you recommended adjuvant endocrine therapy for a high grade DCIS, ER negative, but PR positive that has underwent lumpectomy and adjuvant radiation?
I would not recommend adjuvant endocrine therapy to a patient with high grade DCIS that was ER-negative and PR-positive. Studies such as NSABP B-23 failed to demonstrate a benefit to the addition of tamoxifen to chemotherapy in patients with ER-negative invasive cancers, which has been confirmed on ...
Would you resume durvalumab after several month hiatus due to IO unrelated medical comorbidities that has since resolved?
This is a challenging question and it is hard to know what the right answer is. If the patient's ECOG PS is good, Durvalumab was well tolerated for the most part, and the IO unrelated medical co-morbidities are now under control, I would consider re-initiation of Durvalumab. I would balance risk and...
Would you recommend re-excision in a breast cancer patient who received neo-adjuvant chemotherapy with no residual tumor on pathology, but sterile mucin at the edges was present?
In the absence of viable invasive tumor cells at the tumor margin or in the absence of DCIS < 2mm from the margin, I wouldn't recommend re-excision. I would accept the excellent result of a pathologic complete response and that the presumed needed adjuvant radiation would be an excellent approach.
When chemotherapy is indicated in early stage soft tissue sarcoma, would you prefer to use AD or AI?
I would start by bringing caution to the phrase, "when chemotherapy is indicated in early stage sarcoma." I assume you are asking about adjuvant chemotherapy, and will provide comments with that assumption. The role of adjuvant chemotherapy in resected soft tissue sarcomas remains controversial, and...
How do you decide about neoadjuvant chemotherapy in a women with both IDC and DCIS on biopsy when the tumor is ill defined on imaging?
In the clinical scenario of a palpable tumor and biopsy reflecting a mix of pre-invasive disease (DCIS) and proliferative cancer, the value of neoadjuvant chemotherapy is debatable. The optimal goal of NAC is to ameliorate long term outcome, that was documented with pCR, these quite low in original ...
Would detection of an adverse cytogenetic marker such as dup(1q) alone in the setting of MGUS satisfy criteria for a diagnosis of multiple myeloma?
Short answer, no.Longer answer -The important transition between MGUS/SMM to MM is CRAB criteria (hypercalcemia, renal disease, anemia, bone lesions), OR the development of a myeloma defining events -- >60% clonal plasma cells on bone marrow, multiple lesions on MRI, or FLC ratio > 100. These myelom...
What is your preferred chemotherapy regimen for a fit younger patient with mantle cell lymphoma?
For a young fit patient with mantle cell lymphoma not suitable for observation and in need of treatment, without contraindications to intensive therapy, my preferred approach is to use the MCL Younger strategy of alternating RCHOP and cytarabine-based therapy as induction. I will routinely substitut...
For patients receiving adjuvant trastuzumab for HER2+ positive breast cancer, if a patient misses a dose, do you make up that dose or stop at 1 year mark without making the dose up?
I would typically make up the dose. My reasoning is that the goal of treatment is to increase probability of cure. We know from prior adjuvant trials that decreasing the relative dose intensity (defined as the dose delivered over time divided by the standard, protocol-defined dose of regimen over ti...
How would you advise a pre-menopausal, HR-, HER2+ BC with treated brain metastases and NED while on trastuzumab/pertuzumab who wants to conceive?
I would advise against her carrying the pregnancy. Trastuzumab is associated with a high risk of oligohydraminos so she would need to come off therapy for about 10 months. That could cause any dormant micromets to get out of control during pregnancy and jeopardize the baby and the mother's health.