Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage Cancer-Associated Retinopathy (CAR) in a patient who doesn’t have a known cancer diagnosis, given the difficulty in finding the underlying cancer and the risks of using immunosuppressive treatments to preserve vision?
Auto-immune retinopathy, whether paraneoplastic or non-paraneoplastic, can be a very difficult condition to diagnose and manage. There are a few features that raise suspicion for a paraneoplastic cause particularly, such as rapid progression and more significant intraocular inflammation (anterior ch...
How would you manage a gastric MALT patient with anemia and peri-gastric and abdominal retrocaval nodal involvement?
Of course, I would first want to know if the disease was H. pylori+. Studies have shown that involved perigastric lymph nodes and deep invasion of the gastric wall are associated with a lower chance of achieving a complete response with triple therapy, but in most patients with gastric MALT (a very ...
For ER+ breast cancers that are clinical Stage IIB (T2N1) nearing locally advanced stages, what criteria do you use to determine if you would offer neoadjuvant chemotherapy?
This is an interesting question. Assuming this is regarding ER positive but HER2 negative tumors, the factors I would consider that would favor the decision to use upfront chemotherapy are the following: 1. Tumors that are grade 3 or high Ki-67 2. Low ER positive tumors 3. Younger, premenopausal wom...
Would you recommend adjuvant chemotherapy therapy to a premenopausal patient with ER+ lobular breast cancer who had a partial response to neoadjuvant endocrine therapy?
One approach is if you have enough tissue from the diagnostic core biopsy to run an Oncotype then base your decision on adjuvant chemo from that. This is assuming you are confident she is a N1 case (no treatment effects noted in other nodes). There is an ASCO 2018 abstract from Mayo (Talal Hilal et ...
What is your approach to localized pancreatic cancer that would otherwise be resectable, except for poor patient characteristics?
Tough question—since there is no prospectively validated phase III data to guide us in such situations, we've adopted an approach that utilizes bi-modality treatment sequencing, punctuated with aggressive supportive care and frequent multidisciplinary evaluation (q 2 months) to re-assess eligibility...
How long would you continue second line maintenance PARP inhibitor in a patient with recurrent stage IV BRCA+ ovarian cancer who had CR and remains NED?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. While PFS outcomes are improved with these agents regardless of BRCA mutation status, t...
How do you decide between Nivolumab + Ipilimumab and Pembrolizumab or Nivolumab monotherapy in later lines of MSI-H Colorectal cancer?
The data are fairly clear that patients with the combination of nivolumab and ipilimumab is highly active based on the Checkmate-142 study (Overman, et al, JCO 36, no. 8 (March 10 2018): 773-779, 2018) showing a 55% RR with 5% CR (n=119 patients, all post at least 2 prior chemo regimens). PFS at 12 ...
What would you recommend as adjuvant treatment for a patient with Stage III melanoma?
Good question at just the right time. As of last week the treatment of stage III melanoma has dramatically changed based on 2 trials reported in the NEJM. The first trial in 906 patients demonstrating that nivolumab is superior to iplimumab with much less toxicity, was stopped early because of clear...
Would you recommend adjuvant nivolumab for patients with upper tract urothelial cancer?
For any patient with upper tract UC who is eligible for cisplatin, adjuvant cisplatin based chemotherapy would be the preferred standard of care approach. This would be supported by results from the POUT trial where patients treated with cisplatin were deprived significant DFS benefit compared to su...
Would you provide vitamin B12 supplementation to a patient on pemetrexed therapy if their B12 levels are normal or high?
Yes. B12 supplementation has been shown to decrease the risk of paresthesias.