Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend an allogenic stem cell transplant in an older patient > 50 with Ph negative acute lymphoblastic leukemia who is MRD negative after induction?
In general, I would not routinely recommend allogeneic hematopoietic cell transplantation (HCT) for Ph- acute lymphoblastic leukemia (ALL) that is in MRD-negative remission this early in their treatment. This sort of response demonstrates significant chemosensitivity. Therefore, I would favor contin...
How do you sequence chemotherapy with radiotherapy for advanced endometrial cancer?
Unfortunately, we don’t even know for sure if we need RT for stage III disease.GOG 258 showed early concurrent chemo RT is no better than chemotherapy alone (delaying chemo increased distant mets, which probably negated locoregional control benefit of RT). For this reason, chemotherapy has become st...
Would you consider substituting infusional 5FU for capecitabine in the FLOT regimen for localized gastric adenocarcinoma?
No. I'm not aware of any high-quality data for such a regimen.
How do you manage PSA progression while a patient is on Xofigo or Pluvicto?
The tl;drPSA is very much an imperfect tool for these patients. The data show that PSA may initially increase over multiple cycles before decreasing, though this is a minority of patients. Most patients whose PSA increases early have resistant disease, and you should investigate further with imaging...
Is there any role for PARPi maintenance in BRCA-/HRD- patients after response to front line chemotherapy +/- bevacizumab?
This is a more complex question, and relies on a conversation with the patient and shared decision making. Unfortunately, the benefit seen with PARPi maintenance in BRCA-/HRD- patients was limited (PRIMA 8.1 vs. 5.4 months; PAOLA-1 16.9 vs. 16 months). I am also sensitive to implications of incorpor...
Are you more permissive of perioperative interruption of anticoagulation for VTE depending on the location and relative chronicity of the thrombus?
Yes - in general, I try to balance the relative urgency/importance of the procedure or surgery v. the thrombotic risk to the patient of a period of time off of anticoagulation. Location and chronicity both can feed into determining thrombotic risk. An upper extremity DVT, in general, has a lower rec...
Would you offer adjuvant chemotherapy or radiation to a resected MSS T3N0 high-rectal lesion with low anterior resection without pre-op therapy?
For patients with T3N0 upper rectal cancer with no significant risk factors (R0, CRM clear, no EMVI) who undergo high quality TME surgery as suggested by an intact TME pathologic specimen, the 5-year risk of pelvic recurrence without the delivery of adjuvant radiotherapy is < 5%. I do not recommend ...
What is your experience with transesophageal lung mass biopsies?
Thoracic lesions requiring FNA in the mediastinum are often best approached with EUS–FNA, as the sedation and airway management are less complex than the EBUS, and the needle does not need to break through cartilage rings to access the lesion. On the other hand, a lung mass would require the needle ...
For a patient with well differentiated de novo triple positive metastatic breast cancer who did not respond to THP, do you sequence all available HER2 targeted options before endocrine therapy?
Endocrine combinations for triple positive breast cancer are honestly a bit understudied. We are starting to get more data in this space, SUMMIT, for example, neratinib + fulvestrant + trastuzumab. I think endocrine based combinations are very interesting and there are likely some tumors that are mo...
Would you consider omitting platinum from neoadjuvant chemotherapy in women > 50 years of age with localized triple negative breast cancer?
I would not use the results cited above from the >50 subgroup (which was just 30% of their study population) of the study from the Tata Memorial Centre to justify omission of carboplatin from the neoadjuvant regimen for TNBC in otherwise healthy patients over 50 with TNBC. There is compelling data f...