Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you treat an unresectable MSI-H colon cancer patient with persistent hepatitis C with immunotherapy?
Great question.There are two questions here:Question 1. Should we treat an unresectable MSI-H colon cancer patient with immunotherapy? The answer is yes, based on the data we have from metastatic disease trials such as KEYNOTE-177 and CheckMate 142 studies. We can also use the phase 2 study data fro...
How do you treat refractory cold agglutinin disease?
If the patient has refractory cold agglutinin disease not associated with malignant lymphoproliferative disease, I have used intermediate dose Cytoxan. However, there is recent evidence that inhibition of C1s and thus complement activation by a monoclonal antibody sutimlimab markedly reduces hemolys...
Would you consider using CDK 4/6 inhibitors in a patient with end stage renal disease (ESRD) along with an aromatase inhibitor?
The short answer is yes. Here is why...All three CDK4/6 inhibitors are extensively metabolized by the liver and excreted in the feces. Based on the known PK profiles of all 3 commercially available CDK4/6 inhibitors, there should not be a dose reduction necessary in patients with CKD (although these...
When would you consider adjuvant fulvestrant for ER+ breast cancer if the patient does not tolerate tamoxifen or any of the AIs?
While there are no trials that have assessed adjuvant fulvestrant versus placebo, we know from a small trial (GEICAM 2006-2010) that adjuvant fulvestrant plus anastrozole doesn’t add much when compared to adjuvant anastrozole. In this clinical setting, if the risk for distant recurrence is very high...
Is it appropriate to offer definitive trimodality therapy, as an equivalent option to neoadjuvant chemotherapy followed by radical cystectomy, in patients with muscle-invasive bladder cancer regardless of fitness or platinum eligibility?
There are now several retrospective studies utilizing advanced statistical techniques suggesting that outcomes after trimodality therapy (TMT) are very similar to those after surgery (e.g., Zlotta et al., PMID 37187202, Brück et al., PMID 37517601, and Kulkarni et al., PMID 28410011). These findings...
How should we address the questions about the use of hormone replacement therapy in post-menopausal women who have concerns about its relation to breast cancer?
I am presuming that we are referring to woman that does not have breast cancer. Overall, long term estrogen replacement, especially combined with a progestin, is used much less these days since the Women's Health Initiative trials found an increases in coronary heart disease (CHD), breast cancer, pu...
How do you approach patients who progress on maintenance atezolizumab after platinum based chemotherapy for extensive stage small cell lung cancer?
At this time I have not yet had this experience. However, the approach should not be very different from that of treating a patient who has progressed after initial chemotherapy with platinum/etoposide who are on observation after having completed 4-6 cycles. If there has been a significant interval...
In what circumstances would you stop therapy for patients with metastatic HER2+ breast cancer with long-term complete response to HER2-directed therapy?
When a patient is having a very durable and long-term response to HER2-directed antibody therapy, I would typically stop the therapy only if issues related to it (such as decreased EF) arise or if the patient desires to stop. To my knowledge, there are no great retrospective reviews or studies guid...
For patients with metastatic adenocarcinoma of the lung, do you base any treatment decisions on EGFR gene amplification?
There are no proven predictive uses for EGFR amplification in lung cancer. In a negative trial of necitmumab, patients with EGFR amplification had a positive outcome in the EGFR amplified subset, but this was an unplanned analysis and is thus hypothesis generating rather than proven. The hypothesis ...
Is it true that a ferritin above 200 essentially rules out iron deficiency?
No, I do not think that a ferritin >200 ug/L essentially "rules out" iron deficiency. Ferritin is an acute phase reactant and can be elevated in myriad conditions including kidney disease, autoimmune disorders, etc. The transferrin saturation (measure of serum iron/TIBC) is an important marker of ir...