Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adjuvant olaparib in a patient with HER2+, high-risk, early stage breast cancer with germline BRCA mutation?
We do not yet know whether HER2 amplified cancers in women with BRCA mutations are in fact driven by HER2. However, given the remarkable efficacy of anti-HER2 therapy, I would be loath to discard the accepted strategies for managing HER2-positive disease. There is also a pragmatic challenge which is...
For a post-menopausal woman with a pT1c node negative HER2 positive breast cancer, does ER status influence your choice of adjuvant paclitaxel/trastuzumab versus docetaxel/carboplatin/trastuzumab?
Data from pivotal trials addressing adjuvant therapy options for HER2 positive cancers, like BCIRG 006 and APT, doesn't support treating ER positive, HER2 positive cancers any differently than ER negative, HER2 positive cancers.BCIRG 006 that showed TCH regimen to be as good as ACT-H (and superior t...
What is your preferred first line treatment for patients with high risk MDS who are not candidates for transplant?
My choice of first-line therapy for high-risk MDS patients that are not transplant candidates tends to still be a hypomethylating agent (HMA). I send a myeloid molecular profile on all my MDS patients and use the p53 mutation status to make a decision regarding azacitidine vs. decitabine use. For pa...
What is your preferred first line treatment for patients with high risk MDS who are not candidates for transplant?
My choice of first-line therapy for high-risk MDS patients that are not transplant candidates tends to still be a hypomethylating agent (HMA). I send a myeloid molecular profile on all my MDS patients and use the p53 mutation status to make a decision regarding azacitidine vs. decitabine use. For pa...
Would you continue adjuvant nivolumab or pembrolizumab in a resected stage III melanoma patient that developed local-only recurrence at the site of previous surgery?
I am presuming that the patient is experiencing an in-transit recurrence while receiving anti-PD-1 monotherapy. Whilst, the intention for anti-PD1 monotherapy in the adjuvant setting is to prevent distant relapses, an in-transit recurrence is the most difficult to treat with systemic therapy. In our...
How would you manage LPL with associated AL amyloidosis?
My approach here would depend upon the nature, impact, and severity of the amyloid. Is the LPL IgG or IgM secreting? Is the amyloid causing immediate physiologic harm (renal, cardiac) or asymptomatic radiographic deposits? How much lymphoma and amyloid, respectively? Treatment options include Benda,...
After R1 resection of a locally advanced, node-positive neuroendocrine tumor of the terminal ilium, would you offer adjuvant radiation therapy?
This is a very nuanced question, and I disagree with those suggesting radiation. The great majority of NETs occur at the terminal ileum and the great majority of these tumors are grade 1 or 2. If there was a positive margin it could take many years for that disease to manifest locally. I think radia...
How do you approach adjuvant chemotherapy for high risk/advanced endometrial cancer patients?
For patients with high risk/advanced endometrial cancer where adjuvant therapy is advised, I recommend paclitaxel (175 mg/m2) + carboplatin (AUC 6) (TC) every 3 weeks for 6 cycles. Data from GOG #209 strongly support this recommendation. In this large prospective study, TC demonstrated noninferiorit...
How do you approach hemorrhagic brain metastases in melanoma?
This is a symptomatic brain metastasis from melanoma. Such patients had poor outcomes in the CheckMate 204 trial with dual IO therapy alone. Local control with RT therapy is advised. In our practice, we start with IO-therapy and radiation joins in whenever they are ready with the plan (as GKRS plan ...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...