Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...
How would you treat an MSI-H metastatic cholangiocarcinoma found on liquid biopsy?
This question has come up several times over the years at the Cholangiocarcinoma Foundation Conference. Several case outcomes were presented by numerous colleagues.We are, in fact in the process of finishing up a series on this exact scenario.At present, I have 2 active patients where from the insur...
How would you manage a patient with synchronous breast and ovarian cancer, s/p neoadjuvant chemotherapy and surgery for ER+/HER2- breast cancer and found to have an ER+ ovarian cancer nodal metastases at TAH/BSO?
I usually treat my triple negative breast cancer patients (whether or not there's a deleterious mutation in the homologous recombination repair pathway, e.g. BRCA1 or BRCA2) with neoadjuvant docetaxel + carboplatin. The addition of carboplatin to taxane-based neoadjuvant chemotherapy regimens was ev...
How do you manage AEDs in patients with malignant brain tumors?
Use of prophylactic anti-seizure drugs in patients with primary malignant brain tumors is not recommended and has been evaluated in multiple systematic reviews and guidelines including a recent systematic review and well-done guideline paper from SNO and EANO published by Tobias Walbert, Elizabeth G...
Do you recommend post-mastectomy RT for a premenopausal woman with ER/PR+ Her2 negative breast cancer and Li-Fraumeni syndrome with RCBII and residual disease in multiple LNs following neoadjuvant chemotherapy?
I have been very reluctant to offer RT for patients with Li-Fraumeni syndrome as in limited published data, the risk of RT-induced second malignancy can be as high as 25%. Any potential benefit has to be weighed against the risk. In the above case, need to look at the entire clinical scenario and qu...
In a patient with serous ovarian adenocarcinoma who presents with SBO due to focal involvement of the small bowel, but who has other extensive metastases and cannot get chemotherapy due to bone marrow compromise, would you recommend palliative RT in addition to venting G-tube placement?
Assuming she is expected to be platinum-sensitive and otherwise a good surgical candidate, then I would recommend an ileostomy and G-tube. I would avoid RT.
Do you routinely do restaging imaging before surgery for a patient who completed neoadjuvant treatment for MIBC?
Clinical staging of MIBC is suboptimal despite the advent of multiparametric (mp)-MRI. However, routine radiographic restaging following neoadjuvant chemotherapy and before radical cystectomy is prudent in patients with baseline cT2-T4aN0 MIBC and is generally required in clinical trials. It is know...
Would you consider administration of neoadjuvant anthracycline for cT2N1 ER+/PR+/HER2- patients given that this may be excessive for N1 disease, or do you wait until nodal status is confirmed on surgical pathology?
Yes, I would consider anthracycline-based therapy in cT2N1M0 HR+/HER2-negative breast cancer. The ABC trial, the only large-scale trial testing anthracycline specifically in HER-negative cases, showed only a marginal benefit in disease-free survival (not quite statistically significant), and appeare...
How would you approach post-chemoradiation consolidation in a patient with stage III lung adenocarcinoma with an EGFR exon 18 G719A mutation and highly positive PD-L1 level?
Based on currently available FDA-approved therapies, osimertinib is a suitable choice. While G719A is an atypical EGFR TK mutation and some studies show that this variant may be less sensitive to osimertinib compared to the other classic mutations, the same retrospective studies also show clinical e...
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...