Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you select first-line therapy for PD-L1-positive metastatic TNBC?
For patients with PD-L1 CPS greater than 10, regardless of germline BRCA1/2 pathogenic variant status, my first-line treatment of choice is pembrolizumab combined with sacituzumab govitecan (SG) or chemotherapy based on the ASCENT-04 trial. In ASCENT-04, SG plus pembrolizumab improved median progres...
Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?
Tough question, with lots of evolution in this area in the past few years. The data would suggest that for borderline resectable pancreatic cancer, there is a benefit in terms of OS from preoperative treatment. For unresectable disease, the small chance of conversion into resectability is worth the ...
How do you counsel patients and caregivers regarding management of cancer-associated cachexia?
ASCO guidelines re: anorexia/cachexia were just published in May 2020. Basically, they note the magnitude of the clinical problem and the limited therapeutic options proven to be helpful. They state that dietician consultation is reasonable to employ. They also note that it is reasonable for a clini...
How do you approach a stage IIIC triple positive IDC, s/p neoadjuvant TCH and P, lumpectomy, and ALND with significant residual disease at the time of surgery?
I would use adjuvant T-DM1 for residual disease after standard neoadjuvant therapy for HER2+ breast cancer as described in this case. We have strong evidence from the KATHERINE randomized trial that adjuvant T-DM1 compared to trastuzumab that cuts recurrence risk by about 50% in this situation. Whil...
What would you use as adjuvant endocrine therapy for a patient who developed an invasive, hormone receptor positive breast cancer while on raloxifene for almost a decade prior?
In this situation I would use an aromatase inhibitor if possible. One would not expect an ESR1 activating mutation to be readily detected after treatment with a SERM, since estrogen deprivation rather than receptor blockade enriches for ESR1 mutant clones.
In a patient with inflammatory triple-positive breast cancer who has a pCR to neoadjuvant chemotherapy, but has an incidentally found focus of intermediate-grade ER+/PR+/HER2- ILC in the mastectomy specimen, how would this impact your adjuvant radiation recommendations?
This finding would not have any impact on my recommendations, since her management needs to be guided by the inflammatory breast cancer. That means chest wall plus nodal irradiation tailored to the findings of axillary surgery. There are no data on whether we can decrease the dose in patients with a...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
Do you recommend routine surveillance MRI brain for asymptomatic patients with metastatic HER2+ breast cancer?
I do not perform routine screening or surveillance MRI of the brain for asymptomatic patients with HER2 positive metastatic breast cancer. But I do have a low threshold to order brain imaging in such patients for early/minimal symptoms. My reasons for not performing routine screening/surveillance MR...
In the setting of COVID-19, would you perform a SLNB for a patient incidentally found to have microinvasive ER+ ILC in contralateral prophylactic mastectomy following neoadjuvant chemotherapy for a locally advanced triple positive breast cancer?
I would not recommend SLN biopsy, independent of COVID-19. This patient's prognosis is overwhelmingly dependent on the locally advanced triple negative breast cancer, not the microinvasive ER positive breast cancer. Acknowledging that the ER positive cancer may have been larger than microinvasive be...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...