Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients who initially received chemo-hormonal first-line therapy for metastatic prostate cancer followed by abiraterone/enzalutamide for castration-resistant disease, would you re-challenge with docetaxel?
As we all know, very few things regarding therapeutic sequencing in prostate cancer are straightforward. Retreatment with docetaxel was used relatively commonly in the past in patients with mcrpc, especially in those with good initial responses primarily for want of other agents. In this setting, re...
When do you consider it too late after breast surgery to offer adjuvant chemotherapy to a patient with high risk non-metastatic breast cancer?
While we have evidence that it is beneficial to begin adjuvant chemotherapy soon after surgery, especially in younger patients with TNBC, we have no answers to the question of when it is 'too late' to start treatment. And while there are theoretical biologic advantages to starting treatment of possi...
How would you treat a patient with BRAF mutated Metastatic Melanoma who has progressed on targeted therapy (Encorafenib + Binimetinib) and Immuotherapy (Nivolumab/Ipilimumab), but yet maintain an excellent performance status?
Agree that clinical trial access would be ideal. If unable to access for any reason or to "bridge" if the patient is symptomatic, one might consider re-treatment with BRAF/MEK inhibitor based on phase II and retrospective data demonstrating response (Schreuer et al.: Combination of dabrafenib plus t...
How do you treat de novo metastatic hepatocellular carcinoma in a non-cirrhotic patient with a prior orthotopic liver transplant for hepatitis B now on chronic immunosuppression?
What adjuvant treatment would you use for a cisplatin ineligible, node positive, upper tract urothelial cancer patient after radical nephroureterectomy?
Based on the recent POUT trial, there is no benefit in substituting cisplatin with carboplatin. In fact, node positive patients tended to do worse even with chemotherapy. I routinely consider adjuvant IO trials for these patients like AMBASSADOR. If patient is not able to participate in trials, it m...
How do you manage elderly patients with borderline PS and ER+ inflammatory breast cancer without metastasis?
Consideration of chemotherapy in this particular case will depend on a number of factors including: specific commodities, cardiac risk factors , and overall performance status. CARG tox calculator may help in teasing out potential for toxicity vs. benefit from treatment. Biological characteristics o...
In a patient with liver metastases from a pancreatic NET, that have been successfully treated with ablation by interventional radiology, would you resect the primary pancreas lesion?
Grade absolutely matters here. The number of liver mets and other extent of disease also matter. For low-grade pancreatic neuroendocrine tumors (PNET) with liver only metastases who are good candidates for surgery, resection can be considered. Benefit was seen in this study with locally advanced PNE...
How would you treat DLBCL of the terminal ileum in an otherwise healthy patient?
Primary intestinal Diffuse large B cell lymphoma (PI-DLBCL), even if found incidentally on a screening colonoscopy in an asymptomatic patient, should be treated with systemic chemotherapy similar to what is done with nodal DLBCL. With this approach, the prognosis for PI-DLBCL is very good based on t...
Would you treat prostate cancer with hormone sensitive metastatic recurrence (after local treatment) the same as de novo metastatic hormone sensitive disease?
Yes, most of the phase 3 trials (ARCHES, ENZAMET, TITAN, STAMPEDE) permitted relapsed mHSPC patients in addition to de novo mHSPC patients. LATITUDE was the only trial that required newly diagnosed patients with mHSPC. For the AR inhibitors, a similar benefit in delaying radiographic progression or ...
In transplant-eligible, fit patients with primary refractory myeloma, what is the optimal timing for stem cell collection?
In fit patients with less than a partial response to induction therapy, i.e. primary refractory, the optimal timing for stem cell collection is NEVER. If they don't respond to three drug induction (proteasome inhibitor + IMiD + steroid), they are unlikely to respond durably to a standard high dose m...