Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a young patient with stage I follicular lymphoma of the mesenteric lymph nodes?
This is an excellent question that is often discussed in guideline panel meetings- with a fair amount of disagreement among parties. As radiation therapy leads to long-term disease control in ~50% of patients with stage I FL (and is not cured with either chemotherapy or immunotherapy), my preference...
What are your treatment options for HER2 over-expressing metastatic breast cancer in a patient whose LVEF decreased to <50% from normal baseline on HER2-directed therapy and EF fails to improve after holding therapy for 2 months?
The decision for stopping HER2 therapy for cardiomyopathy should be weighed against the risk of their metastatic disease progressing on suboptimal therapy. With closer monitoring and help from a cardiologist to optimize medical management, I have been able to continue effective anti-HER2 therapy in ...
How would you treat a locally-recurrent extraosseous (pulmonary) Ewing sarcoma?
It is possible to re-challenge the patient with the same regimen. Assuming EF and BNP are normal and can be followed, bolus Doxorubicin with Dexrazoxane would allow safe administration of additional doxorubicin. The alternative is to use high-dose Ifosfamide (14 g/m2/cycle). In the event of a good v...
Would you consider SBRT for node negative small cell carcinoma of the prostate?
There are no prospective data to guide the use of RT in the management of small cell carcinoma of the prostate. Retrospective data would suggest possible benefit at least in terms of control of disease in the prostate with the addition of local RT to systemic chemotherapy (see Oke et al., PMID 33824...
Do you ever offer scalp cooling therapy to metastatic breast cancer patients wishing to avoid alopecia?
I routinely offer scalp cooling to such patients. I do acknowledge to patients that we do not have evidence to support scalp cooling in the metastatic setting, that the best evidence to support its efficacy is with taxane-based regimens, and that we really cannot be sure how or if scalp cooling will...
Would an STK11 mutation influence your choice of single vs combination immunotherapy in a patient with MSI-H metastatic CRC?
The presence of an STK11 mutation would not affect my decision to offer immunotherapy for an MSI-high (dMMR) colorectal cancer patient. There is mixed literature about if this might portend a better response to IO treatment (Kwon et al., PMID 32284250.) One should note that with a KRAS mutation in l...
How does avidity on DOTATATE PET impact your choice of whether to start somatostatin analogues in metastatic neuroendocrine tumors?
A negative DOTATATE scan is predictive for a lack of response to SSA therapy including Lutathera so I would not use octreotide or lanreotide for this patient and I would choose something else for treatment. (See for example Lee et al., PMID 32886441)
What, if any, adjuvant therapy would you offer a high risk (based on size, location, mitotic rate) GIST patient who is wild type or PDGFRA D842V mutated?
Unfortunately, there is no evidence that would support the use of postop adjuvant therapy for WT (regardless of the subtype) or PDGFRA D842V mutant high-risk GIST. The SOC would be close observation and consider mutation-appropriate options with measurable/evaluable disease.
How would you manage a patient with PSA relapse 10 years after salvage radiotherapy with PSA doubling time<6 months?
Depending on PSA, would image with PSMA PET - typically, will do around PSA 0.5 or higher (given most insurances will not cover multiple PETs in a short timespan, and detection rates of ~50% at PSA 0.5-1 per CONDOR). If no targetable (by XRT) disease on that, would discuss ADT given increased risk o...
Would you consider adjuvant immune checkpoint inhibitor therapy for non-small cell lung cancer patients with residual disease after neoadjuvant chemoradiation and surgical resection?
Prior radiation was an exclusion criteria for adjuvant atezolizumab in IMpower010. Also, neoadjuvant chemotherapy was not permitted and patients only received 4 cycles of adjuvant cisplatin based chemotherapy prior to atezolizumab. So this would be outside the scope of the trial. That being said, I ...