Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider dual anti-HER2 therapy for a perimenopausal woman found to have multifocal pT1mic pN1mic HER2+ HR- breast cancer following a bilateral mastectomy for DCIS?
The optimal treatment for DCIS with microinvasion DCISm is not fully established. There is a nice analysis and discussion from Si et al., PMID 33344258 outlining the factors for worse outcomes. Her multifocality, ER-HER2+ status, and most importantly, nodal involvement increases her risk compared to...
Would you give chemotherapy to a fit patient with myxoid liposarcoma of the knee that is resectable with adverse functional outcomes who will be undergoing neoadjuvant radiation and resection?
I give ifosfamide to people with myxoid/round cell liposarcoma.In general, I do not give adjuvant chemotherapy to adult-type soft tissue sarcomas because of the phase 3 EORTC studies showing that it did not improve survival.Le Cesne et al., PMID 25294887 But I do give ifosfamide to people with myxoi...
Do you give an etoposide-based regimen/more aggressive therapy for lymphoma-associated HLH, such as da-EPOCH-R over R-CHOP?
The general approach to treat the secondary lymphoma-associated HLH (LA-HLH) is to treat the underlying lymphoma- it works better in B cell lymphoma. Etoposide is probably the only agent consistently that has been shown (in several studies- mostly retrospective) to make a difference in the resolutio...
How do you manage HER2+ metastatic esophageal cancer in frail and elderly patients?
A standard, intensive approach to management of metastatic, HER2+ esophageal cancer would be with FOLFOX-trastuzumab-pembrolizumab, based on the KEYNOTE-811 study and subsequent FDA approval. How to adapt this to a frail, elderly patient depends on the degree of frailty, and the approach will not be...
How do you approach the decision to pursue early versus delayed autologous stem cell transplantation in newly diagnosed multiple myeloma?
An excellent discussion.Why do I have a feeling this will continue to be debated for the next decade?!Reasons to consider early transplant: Age > 65. These patients were not included in the IFM-2009 study that tried to answer this. Patients who defer transplant in this age range may never get to a t...
What adjuvant therapy would you offer a post-menopausal CHEK2+ patient with HR+ HER2+ T1bN1 breast cancer and concurrent HR+ HER2- T1N0 disease?
These are hard cases. In general, the HER2 positive disease will take priority. Although it would be ideal to have treated the patient neoadjuvantly to assess response and potentially offer adjuvant TDM-1 per the KATHERINE trial, for now, I would optimize her therapy with adjuvant TCHP for 6 cycles ...
How would you treat a patient with metastatic RCC who developed posterior reversible encephalopathy syndrome (PRES) on a TKI-containing regimen?
PRES is a clinical-radiological diagnosis. The pathology (to my knowledge) is not yet clearly defined though is thought to be the consequence of vascular permeability compromise. There are known triggers of this disease including chemotherapy, auto-immune conditions and VEGF-TKI therapy, and hyperte...
How would you treat a young patient with metastatic colorectal cancer who initially tolerated 12 cycles of FOLFOX + bev with disease progression after cycle 3 of maintenance 5-FU + bev?
TRIBE and TRIBE2 studies showed convincing evidence of triplet chemotherapy FOLFOXIRI/bevacizumab has PFS, and more importantly, OS benefits for patients with metastatic colorectal cancer (mCRC) and now, this regimen has been used in our routine clinical practice more and more frequently especially ...
What features help distinguish thyroid myopathy from immune checkpoint inhibitor-associated myopathy?
Immune checkpoint inhibitors (ICIs) can cause myositis (ICI-myositis). Since ICIs can also induce hypothyroidism, myopathy secondary from hypothyroidism can also be associated with ICI therapy. Different from thyroid myopathy, patients with ICI-myositis barely have myoedema or muscle pseudohypertrop...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.