Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you reconcile discrepancies in clinical prostate cancer staging with AJCC and NCCN?
Fundamentally, I use NCCN risk categories to help steer conversations about staging and treatment options for very low vs low vs fav int vs unfav int vs high risk diseases. Therefore, I use NCCN staging in my clinical practice and notes and incorporate mpMRI into staging. I find it comforting that N...
Is 5fx APBI and no endocrine therapy a new standard of care for women over 70 years old with low-risk breast cancer given the interim analysis of the EUROPA trial?
How do you ask a woman to be the last woman to suffer for an unlikely, non-lethal recurrence? For women with low-risk breast cancer, endocrine therapy does not improve survival and is less effective at decreasing recurrences—we saw this in NSABP B-21. Yet it causes years of suffering: arthralgia, ho...
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
What is your preferred treatment for refractory warm autoimmune hemolytic anemia with autoimmune neutropenia?
For immunomodulation, have you trialed IVIG? If not, this would be worth a trial. For immunosuppression, I prefer to utilize a more T cell-directed agent after failure of steroids/rituximab. Thus, a trial of MMF or cyclophosphamide may be reasonable. I think MMF may take too long to work in a situat...
Would you offer radiation for a plasmacytoma found on piecemeal endoscopic resection of an initially presumed nasal polyp if subsequent PET/CT was negative and no surgical margin status was known?
In general, unless an oncologic procedure was performed to address a solitary plasmacytoma, I would recommend a course of RT. For a lesion removed piecemeal, the risk of residual microscopic disease is quite high. As the lesion was small and only microscopic disease (presumably) remains, given the n...
Would you consider first line osimertinib to patients with an EGFR Exon 18 G719X mutation?
Yes, I would consider osimertinib. Afatinib is the only EGFR TKI that is FDA-approved for the rare sensitizing EGFR mutations based on pooled data from LUX-Lung 2/3/6. These studies included 18 patients with G719X mutations with a RR 78%, PFS 14 mo., and OS 27 mo. (Yang et al., PMID 26051236) Other ...
Would you offer adjuvant chemotherapy for MSI-H Stage II colon cancer with multiple high risk features?
About 15-20% of colorectal cancers are found to be MSI-high. These tumors are generally associated with a superior prognosis to those who are MSI-stable. Thus, the question as to whether one should utilize adjuvant chemotherapy in the context of patients with stage II disease, a setting where adjuva...
What does bevacizumab contribute in metastatic cervical cancer when used in combination with a platinum doublet + pembrolizumab?
I'm not sure how to answer the question. GOG 240 established paclitaxel/carboplatin/bevacizumab as the standard for first-line therapy for metastatic or recurrent cervical cancer.The BEATcc trial was a subsequent phase III trial for stage IVB, recurrent or metastatic cervical cancer that randomized ...
How would you treat a patient with HER2 positive CNS only progression on fam-trastuzumab which had previously progressed on tucatinib/capecitabine/trastuzumab, and has failed both SRS and WBRT?
I would present or refer her case to a multidisciplinary tumor board to 1) review her MRI to confirm there is progression vs. therapy changes, 2) see if she is a candidate for resection or irradiation of the progressing lesion (possibly using bevacizumab to reduce risk of radiation necrosis), and 3)...
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...