Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach treatment in recurrent, localized rectal mucinous adenocarcinoma?
Well-differentiated mucinous rectal adenocarcinoma is relatively treatment resistant. In general if there is an in-field local recurrence after prior radiation (ie: is not a marginal miss), then that is very good evidence that it is radiation resistant. There are many studies now showing that re-irr...
How do you treat a fit patient with a solitary pulmonary nodule (2cm) which is biopsy-proven small cell lung carcinoma?
Clinical stage I SCLC is vey rare but does happen. In the past this was referred to as "VERY" limited disease. We would recommend surgery, either lobectomy or just a wide wedge resection but with nodal evaluation. This patient would need adjuvant chemo with 4 courses of cisplatin (or carboplatin) + ...
When do you consider employing the 4-week dosing schedule for nivolumab?
I am beginning to see harsher toxicities while using 480 every 28 days so I have begun to revert back in those pts to 3 mg/kg every two weeks to be able to continue. So far so good but sample size too small. I am wondering whether others have opinions about this. Would be a precedent for dose reduct...
How do you counsel patients on multivitamin use during therapy?
I tell patients to stop intake of anti-oxidant multivitamins (A,C and E) at the time of consultation, and if they so wish, they can resume them no sooner than 6-8 weeks after course completion because "radiation continues to work after we're done." I simplify how radiation attacks/kills the cancer D...
Do you recommend routine dental evaluation for all patients before starting bisphosponates in patients with bone metastases?
Yes. The purpose of a dental exam prior to starting IV bisphosphonates or SC denosumab is to survey the mouth and fix any root canals, extractions, or other dental pathology prior to starting of drugs. Why? Because dental extractions during treatment with bisphosphonates or denosumab are one of bigg...
Is carboplatin/pemetrexed as effective as cisplatin/pem in treatment of unresectable malignant pleural mesothelioma in a patient with contraindication to cisplatin?
The combination of carboplatin/pemetrexed instead of cisplatin/pemetrexed is definitely reasonable in older mesothelioma patients and/or patients with comorbidities or concerns about poor tolerability to cisplatin. At least three phase 2 non-randomized studies evaluated the combination of carboplati...
When in the treatment algorithm for pancreatic/GI NET do you recommend interferon?
Our team uses interferon only occasionally and generally later in the algorithm. With randomized data to support agents with favorable toxicity profiles, such as somatostatin analogues, everolimus, and PRRT, these options are frequently preferable.However, older randomized data (Kolby et al., Br J S...
How do you manage a patient with metastatic prostate cancer who does not acheive a PSA response to upfront ADT?
First and foremost, of course, confirmation that androgen deprivation (ie testosterone <50 ng/dl) has been achieved should be obtained. While uncommon, primary resistance to a particular hormonal agent can occur. In this case, an alternate agent can be tried (eg switching from an LHRH-R agonist to a...
How would you treat a pregnant woman in the third trimester with locally advanced, hormone receptor positive, HER2 positive breast cancer?
Given good amount of safety data on anthracycline therapy during pregnancy, favor doxorubicin cyclophosphamide x 3-4 cycles (depending on time of delivery) given every 3 weeks without peg-filgrastim support. With less data with growth factor support, lean toward avoiding in this situation. Will avoi...
Is concurrent intrathecal therapy necessary with HD-MTX for CNS lymphoma?
Generally, high dose methotrexate has high penetration into the CSF so you do not need to give concurrent intrathecal therapy. The only time you might consider it is if they still have persistent disease in the CSF despite the high dose methotrexate. The approach does not change for primary vs secon...