Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Given the final publication of NSABP B-51, for which patients meeting trial eligibility would you still recommend regional nodal irradiation?
The very first thing that should occur before one makes a decision about what they are going to do is to understand how the trial was designed and who was actually accrued to it. The first point is that B51 was a superiority and not a non-inferiority trial. A very related point to that is that they ...
When do you choose dose-dense chemotherapy v. q3 week therapy in advanced epithelial ovarian cancer?
In our recent OGR, we suggested an approach to deciding which patients might be appropriate for considering the dose-dense regimen in the first line setting (Figure 2). The dose-dense JGOG regimen was shown to confer an overall survival advantage in newly-diagnosed patients with advanced disease (es...
How do you determine which systemic therapy to recommend in the 2nd line setting for metastatic, PD-L1 NEGATIVE cervical cancer?
This is a very difficult situation because none of the available options are effective. Clinical trial or possibly pembrolizumab on compassion-care usage.
Is there a role in sending liquid biopsy for patients progressing on ALK inhibitors?
We believe there is increasing value in testing for acquired resistance mechanisms and thereby sending liquid biopsies in patients who progress on ALK inhibitors. The importance was not previously observed as much in patients who progress on first generation crizotinib, since many patients will resp...
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,...
Can a breast cancer patient who received chemotherapy with AC during her 3rd trimester breastfeed before resuming chemotherapy postpartum?
Yes, completing the course of chemotherapy after 6 months of breastfeeding is likely better than not completing it. This is mostly based on the assumption that the chemotherapy sensitivity of micrometastasis is unlikely to change too much over 6 months. If it was potentially curable 6 months ago, it...
How would you manage locally advanced, resectable gastric cancer that is MSI-H?
I would not recommend FLOT + durvalumab for MSI-H gastric/GEJ patients. I say this because there is mounting evidence that chemotherapy may not provide a significant benefit for these MSI-H patients at all (1). All efforts should be made to spare this patient population from getting cytotoxic chemot...
Would you prioritize TACE or systemic therapy in BCLC B multifocal HCC with tumor bulk higher than "up to 7?"
This is a challenging area where we need more definitive studies. With the info available, I do favor systemic therapy for such patients. Liver directed therapy is unlikely to lead to adequate control for such multifocal disease and the patient is likely to require multiple treatments to different a...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...