Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there a role for checkpoint inhibition in patients with advanced, high PD-L1 expressing, chemotherapy-refractory thymoma?
I agree with @Dr. First Last. For now, I would not treat thymoma patients with immune checkpoint inhibitors outside of a clinical study, based on the serious and frequent immune-related adverse events seen in this population as detailed above. There are several single agent chemotherapy options for ...
How do you manage a newly diagnosed locally advanced ER+/HER2- breast cancer with synchronous diagnosis of metastatic melanoma?
When dealing with two concurrent malignancies you need to look at the overall prognosis for both of them to determine the best course of action. If the melanoma was oligometastatic and resected to NED or had a complete durable response to immunotherapy then one could consider more aggressive curativ...
How do you manage elderly women with high-risk HER2 positive disease with baseline low ejection fraction?
Aside from avoiding use of an anthracycline, I would treat them with a chemotherapy regimen appropriate to their disease stage and overall medical condition - which may mean using a less intensive or shorter regimen than I would in a younger, fit patient with the same stage of HER2+ disease - plus t...
What systemic chemotherapy do you prefer with concurrent radiation therapy in the neoadjuvant setting for early stage rectal cancer?
In this setting, I always prefer capecitabine for the sake of patient convenience. If there is a reason I can't use it (e.g. renal insufficiency, poor compliance with oral medications), I opt for infusional 5-FU. I would only consider bolus 5-FU if the patient experienced coronary vasospasm with cap...
In view of possible equivalent efficacy of low dose abiraterone with food, has anyone had clinical experience offering low dose abiraterone to spare patients from financial toxicity of abiraterone?
The Szmulewitz study is a well done and robust pharmacokinetic study of low dose abiraterone with food. There is a well written commentary from Glenn Liu in the same issue of JCO.While the study does show pharmacokinetic equivalence, it is difficult to extrapolate comfortably to clinical equivalence...
Do you routinely offer neo-adjuvant chemotherapy for patient with triple negative metaplastic breast cancer?
I generally offer neo-adjuvant chemotherapy for all patients with triple negative breast cancer that are larger than 1cm. Triple negative breast cancer, metaplastic or not, is comprised of a large group of heterogenous cancers. These patients all need chemotherapy and giving it in the neoadjuvant se...
Would you use immunotherapy in a patient with metastatic lung adencoarcinoma, high PDL1, but had polymyositis as a presenting paraneoplastic syndrome?
I personally would not start with a PD-1/L1 inhibitor in this population. Many trials with this class of immune checkpoint inhibitors allowed patients with autoimmune histories to be included if they had not required treatment for a prolonged period of time. Given the potential debilitating nature o...
What would you choose as the second line treatment option for a stage IV EGFR mutant lung adenocarcinoma that has progressed on osimertinib?
The best choice for 2nd line treatment after progression on osimertinib depends on multiple factors. If a patient has progressive disease in only 1 area while all other areas are well controlled, you could consider local therapy (SBRT or EBRT) to that one area of progression, and continue the osimer...
How would you treat a patient with EGFR+ oligo-metastatic lung adenocarcinoma status post resection of the primary and metastatic sites?
This is a somewhat challenging question - on the one hand, the patient has metastatic (albeit "oligo" metastatic) cancer and systemic treatment with osimertinib is clearly indicated and appropriate for metastatic EGFR mutant lung cancers. On the other hand, all known disease has been resected, and t...
Are the cardiac risks of LHRH agonists also seen in patients undergoing bilateral orchiectomy for ADT in hormone-sensitive prostate cancer?
Although the true implications of testosterone suppression on cardiac risk/disease remains somewhat undefined, it is the low testosterone levels, not the mechanism of how these levels were obtained i.e. either surgical or medical castration that is the issue.