Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When do you expect the 2023 FIGO staging for endometrial cancer to become adopted clinically in the US?
Agree with the previous comment. Current adjuvant RT for stage I and II are based on mainly histopathological classification (PORTEC-I/II). However, the recent publication of PORTEC-4a (Horeweg et al., PMID 37487144) for stage I/II showed molecular classification predicts response for stage I/II. Mo...
How should molecular studies, in particular the presence of POLE or p53 mutations, be incorporated into the decision to treat an "intermediate risk" endometrial cancer patient with adjuvant therapy after hysterectomy?
PORTEC, ESMO, and SGO guidelines support molecular characterization of endometrial cancer based on the TCGA/ProMisE classifications. p53 is a predictive biomarker for response and prognosis while POLE is prognostic. Based on the most recent SGO clinical practice statement, these can be used to escal...
What chemotherapy would you offer (if any) in a young patient after resection and radiation of a single site of metastatic PDL1 positive, triple negative breast cancer?
This is a challenging situation, as the patient is clearly at very high risk of developing other sites of metastatic disease but there is little data on the benefit of chemotherapy or immunotherapy in reducing that risk, delaying the development of metastatic disease, or improving survival. If the p...
What is your typical approach for soft tissue sarcomas of the buttock?
It is worthwhile remembering that the entire paradigm of conservative/limb-sparing surgery rather than radical surgery/amputation for extremity STS (as defined all the way back to Rosenberg et al., PMID 7114936 and Yang et al., PMID 9440743) *presupposes* that patients also receive RT. Therefore, fo...
Are you planning to start running IHC HER2 testing on all tumor types, even those where HER2 overexpression is less typical, in light of tumor agnostic approval of trastuzumab deruxtecan?
In my practice, I recommend HER2 IHC testing for all patients with advanced cancers, especially for those with epithelial cancers. For patients in whom HER2 positivity is rare, I also take into account any concerns about tissue availability as well as clinical eligibility for HER2-targeted therapy.
What is your experience with directing treatment towards the androgen receptor in metastatic triple negative breast cancer?
There are increasing pre-clinical and clinical data of the potential role for targeting the androgen receptor (AR) in patients with metastatic triple negative breast cancer (TNBC) which express AR. Investigated agents include bicalutamide (Gulap et al CCR 2013) and abiraterone (Bonnefoi et al Ann ...
Outside of a clinical trial, do you currently incorporate the TCGA molecular classification into management decisions for patients with endometrial cancer?
I currently do not use the TCGA or ProMisE classifications to inform adjuvant therapy after surgery. Although exciting, it is premature to use this classification until we have the results of PORTEC-4a. These results will help us to better risk stratify patients and guide adjuvant treatment. That be...
How do you differentiate primary from secondary iron overload?
Medical history helps- transfusion history, chronic hemolytic anemias, ESRD on HD, and inflammatory conditions increase the risk of secondary iron. In my practice, I use MRI to help distinguish between primary and secondary iron overload. In primary iron overload, the iron will only be seen in the l...
Do you recommend ADT or other systemic therapy in patients with rising PSA after prostatectomy and salvage RT and PSMA scan negative for metastatic disease?
Generally, I do not recommend systemic therapy for such patients. If doing so, it would be intermittent ADT (alone) for 6-or 9-month cycles. The EMBARK study will hopefully address this important question.
In which scenarios would you utilize sacituzumab govitecan earlier than third line in the treatment of metastatic TNBC?
To date, we do not have a head-to-head comparison of sacituzumab govitecan prior to the 3rd line setting and insurance approval for sacituzumab govitecan prior to 3rd can be a barrier. However, I consider it under the following circumstances: The patient has significant pre-existing neuropathy. Many...