Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In what situations would you recommend adjuvant radiation therapy for patients with locally advanced and/or recurrent basal cell carcinoma that receive vismodegib followed by surgery?
Adjuvant radiation therapy should be considered for locally advanced basal cell carcinomas when surgical margins are positive, or when there is perineural invasion, particularly in high-risk anatomical locations such as the face. This recommendation is endorsed by both the NCCN and the American Acad...
Does pre-chemotherapy extent of nodal involvement impact your decision to offer adjuvant radiation in cN1, ypN0 triple-negative breast cancer?
There are few data on this subject. The group at the Netherlands Cancer Institute in Amsterdam created what they called the "MARI" approach for such patients (Koolen et al., PMID 28524246). In brief, they performed an axillary ultrasound and marked the largest suspicious node with a radioactive seed...
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...
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 ...