Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
At what time do you switch to olaparib after FOLFIRINOX in BRCA mutated metastatic pancreatic adenocarcinoma patients?
Based on POLO - an individual with germline BRCA+ PDAC had to have at least 16 weeks of platinum based therapy (majority had (m)FOLFIRINOX, small # cisplatin/gemcitabine) - before randomization to olaparib or placebo (Golan et alm NEJM, 2019). So, based on the data - this option is there to consider...
How would you treat a patient with extensive-stage small cell carcinoma and severe end-stage COPD on home oxygen?
I would base this decision on the patient's performance status, not solely on a diagnosis of COPD or the use of supplemental oxygen. While the IMpower 133 trial included patients with ECOG PS of 0-1, in the outpatient setting I would generally offer chemoimmunotherapy to a patient with PS 0-2. Pneum...
For patients who have exceptionally long responses to HMA with high risk MDS or AML and not candidate for more aggressive therapy/transplant, do you consider treatment holidays or spacing out doses into longer intervals?
Over time, patients with MDS and/or AML on long-term HMA therapy tend to have lower counts, possibly due to less robust stem cell reserve. In general, we prefer to drop the dose (i.e. from 75mg/m2 to 50 mg/m2 for Azacitidine, from 20 mg/m2 to 10-15 mg/m2 for decitabine) as a first. In some patients,...
What is your approach to oligometastatic HER2 positive breast cancer, particularly after excellent clinical response in all sites of disease to trastuzumab, pertuzumab, and a taxane?
The question of optimal treatment of low burden metastatic HER2-positive breast cancer and complete or near complete response to systemic therapy remains open. The two potential strategies are to continue systemic therapy with HER2-blocking antibodies +/- endocrine therapy or to continue the systemi...
In practice, do you discuss the role of Oncotype Dx before ordering the test?
Yes, I always discuss checking Oncotype Dx first with the patient prior to sending the test. I think it is important to discuss the clinical relevance of the test upfront, as well as the potential implications that may occur as a result of the findings. If a patient is not willing to be administered...
How would you manage a patient with newly diagnosed synchronous triple positive and metaplastic triple negative breast cancers?
Aside from considerations about genetic testing given the dual primaries, and local therapy considerations which I would defer to surgery and rad onc, this case would raise the question of which (neo)adjuvant regimens to consider. I would assess the risk for both cancer independently, and then attem...
Would you resume biologic treatments such as TNF blockers in patients with symptomatic autoimmune conditions who are in remission from their cancers?
Most guidelines in rheumatology recommend use in patients who have been in remission for 5 years or more, there is data for safety for these patients. However, we do not know yet whether TNFi are safe in patients who have been NED for shorter periods and who may be at higher risk of recurrence given...
Should neoadjuvant chemotherapy be recommended for HER2+, clinically LN- breast cancer measuring 2-3cm?
For cT2N0 2-3 cm HER2+ tumors I am still doing neoadjuvant dual blockade chemotherapy for eligible patients in order to assess their pCR status. This guides adjuvant therapy per the KATHERINE study. I usually reserve the APT approach for cT1N0 patients who go to surgery first and are still a stage 1...
How would you approach a patient with Stage III EGFR+ NSCLC who develops oligometastatic disease while on consolidation durvalumab?
This is a difficult situation, I have typically tried local therapies like SBRT initially and then switching to osimertinib with close followup and return precautions
How do you treat patients rendered NED after resection of an isolated lung recurrence of an early stage triple negative breast CA years after adjuvant chemotherapy?
While such patient is at high risk for a subsequent recurrence of metastatic disease, there is no data to suggest that administering 'adjuvant' chemotherapy following resection of a solitary metastasis will improve disease-free or overall survival and thus I would simply continue to observe the pati...