Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there a concern for the potential of future congenital malformations in offspring when preservation of eggs and sperm is done AFTER cyclophosphamide treatment given that it is an alkylating agent?
No, there is not a significant risk of congenital malformations in embryos created with cryopreserved gametes or unassisted pregnancies AFTER cyclophosphamide use. While alkylating agents lead to both male and female infertility, congenital malformations from cyclophosphamide occur when conception h...
How would you approach a patient with symptomatic anal cancer and oligometastatic lesion to the lung?
Systemic treatment is the standard approach for metastatic anal squamous cell cancer. Carboplatin plus paclitaxel or 5FU plus cisplatin are reasonable choices. Recently, the InterAACT trial (Rao et al. JCO 2020) involving 91 patients comparing carboplatin/paclitaxel to 5FU/cisplatin showed similar O...
How would you work up a patient with prostate cancer with bone scan suspicious for metastatic disease and a negative PSMA PET/CT?
While some bone metastases are 99mTc-positive and PSMA-negative, this circumstance is quite rare (< 2%). Based on this alone, in cases like this, I typically conclude that the patient is clinically M0. However, I do consider 3 other factors: the prevalence of bone metastases within the patient’s par...
Does mucinous histology impact your recommendations for neoadjuvant therapy in a postmenopausal patient with HR+ HER2- breast cancer with multiple positive lymph nodes?
My preference in this case (if the patient is resectable) is to do surgery first. This allows confirmation if it is mixed vs pure mucinous on the resected tumor plus pathologic node staging. Not much to be gained by neoadjuvant therapy except if she needs it to attempt surgery. Pure mucinous tumors ...
How does the management of POLE mutated colorectal cancer differ from that of dMMR/MSI high disease?
Finding a POLE-mutated CRC is like winning the lottery. They have a higher neoantigen load than MSI-H disease and elicit deep responses to immunotherapy. Management should be similar, but the response rate is higher in the metastatic setting [overall response rate (ORR) of 89%, significantly higher ...
What is your preferred second-line treatment for high-grade neuroendocrine carcinoma of GI origin after progression on carboplatin + etoposide?
This is a great question. I will try to summarize the current data for treating poorly differentiated GEP-NEC. However, high-grade poorly differentiated GEP neuroendocrine carcinomas (GEP-NECs) are rare cancers, there is an increase in incidence estimated to be 0.2-0.5 per 100,000 inhabitants). (1-2...
For a patient with ENKTL nasal type (nose/sinus involvement) who has hepatic toxicity with pegasparaginase but a CR after 2 cycles of chemotherapy with a plan for "sandwich" radiotherapy - what, if any, chemotherapy would you resume after completion of radiation?
This is an interesting situation as there is not much data. The cure rate is high for early-stage disease after chemoradiation, even with VIPD and no asparaginase regimens (see de Pádua Covas Lage et al., PMID 36446856). Nature reviews which show in Table 2 survival curves similar for asparaginase r...
Would you continue or switch therapy for someone who progressed through AR directed therapy and has a rapid rise in PSA while receiving Ra-223 for bone-dominant castrate resistant prostate cancer?
Certainly, it is reasonable to stop an AR inhibitor that is no longer clinically benefiting a patient irrespective of the use of concurrent radium-223, particularly a second AR inhibitor if there is no evidence of a response. Cross resistance between AR inhibitors is common and a rapid PSA rise sugg...
How do you reason the risk and benefits of low dose vaginal estrogen to a patient on an AI for postmenopausal breast cancer that is suffering from symptomatic vaginal atrophy?
At our Center, we have step-wise approach to vaginal dryness/dyspaurenia. First, establish whether the vaginal dryness is problematic. Most often, the vaginal dryness in-of-itself does not cause problems that impact quality-of-life. The major problem is painful intercourse. Step 1 is the non-hormona...
Would you consider the use of EGFR inhibition (cetuximab/panitumumab) in first line in metastatic right-sided RAS/RAF WT colon cancer, if bevacizumab contraindicated?
This is an area where I’ve seen practice patterns diverge amongst practitioners, even within the same institute, and has been subject to some lengthy discussions within our tumor boards. For me, the short answer is that in general, no, I would not give anti-EGFR to a patient with a right-sided tumor...