Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with driver mutation positive, Stage IV NSCLC who don't benefit from upfront first-line TKI?
It depends on the mutation. EGFR mutants after Osimertinib:- If oligometastatic disease: an option is radiation to the oligometastatic spots and continue osimertinib. It is important to re-biopsy as well due to the possibility of small cell transformation. If transformed to small cell, in general, c...
What is the optimal systemic therapy for dedifferentiated chondrosarcoma?
DD Chondrosarcoma typically has a low-grade cartilage component and the transformed, high-grade component often resembles UPS or osteosarcoma. So we treat these tumors a 'la osteosarcoma, acknowledging that this tends to be a disease of the elderly and appropriate dose/regimen modification will be r...
Under what circumstances would you consider anticoagulation in a young female patient with persistently elevated factor XI activity?
First, get a baseline D-dimer to see how procoagulant she is at that point. If elevated, long travel on plane, pre-op and post-op for 2 months - consider short-term anticoagulation. If past thrombosis - give lifelong anticoagulation. If pregnant - follow D-dimer; if it goes up, anticoagulate.
Which patients with mCRPC on ADT + advanced anti-AR do you treat with bisphosphonates or denosumab?
Men with bone-metastatic CRPC face a relatively high rate of fractures due to bone loss as a result of potent AR inhibition and ongoing ADT but also due to lytic and sclerotic bone metastases which create focal weakening of the bone matrix despite the pathologic bone formation. The fracture rate was...
Does concurrent brain and systemic progression alter your choice of systemic therapy for patients with metastatic SCLC with early progression on chemoimmunotherapy and WBRT?
This is a challenging situation as is expected when treating most patients with ES SCLC. If I give a patient carboplatin with etoposide and a checkpoint inhibitor and they progress shortly thereafter, the standard treatment options are limited. They include single agent chemo such as topotecan, lurb...
In addition to ADT, how would you treat Gleason 8, pure ductal prostate adenocarcinoma with oligometastatic disease?
Based on the available data and knowledge, it is difficult to answer this question definitively.Although prostate ductal adenocarcinoma (PDA), was first described more than 50 years ago and its behavior as an aggressive variant is increasingly being recognized, evidence-based management of PDA is no...
What chemotherapy backbone will you use with pembrolizumab in the neoadjuvant setting for triple negative breast cancer?
I don't have an answer to this, but just opinions. There are several decisions that we will need to make regarding how to best use immunotherapy, unfortunately without much data to guide us:1) What chemo backbone to use?2) Do we really need to continue pembro adjuvantly? If so, in whom? Everyone? On...
Would you consider PRRT re-treatment in a patient with a well differentiated NET previously treated with 4 cycles of PRRT?
Yes, but only for highly selected patients. Might consider discussing retreatment with PRRT (R-PRRT) in those who: 1. Derived good response (or prolonged stable disease) with prior PRRT and,2. Don't have better options available (for example, would not do R-PRRT before CapTem, afinitor, sutent in pN...
What first line treatment would you consider for a patient with stage IV gastric cancer that is HER2 negative and MSI-high?
For a patient with MSI-H, HER2 negative metastatic gastric cancer, PD1 blockade with pembrolizumab (pembro) would be my first choice. The KEYNOTE-062 data support the efficacy of pembro in this setting [Shitara et al., PMID 32880601].The phase 3 KEYNOTE-062 study randomized patients with untreated, ...
Would you give adjuvant therapy for a urothelial carcinoma T2 on TURBT but pTis at margins on cystectomy?
No, this patient would be followed by active surveillance based on NCCN guidelines, e.g. visits, labs, urine cytology, CT chest, CT IVP; would pay attention for any symptoms to upper tract and urethra that may trigger further evaluation. Would discuss with Urologist & Pathologist about the case, the...