Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For unresectable/metastatic cholangiocarcinoma, would you continue gemcitabine/cisplatin beyond 24 weeks if the patient continues to have a response to therapy?
I frequently continue beyond the 24 weeks used in the ABC-02 trial. Despite scarcity of good quality evidence, some form of maintenance chemotherapy is increasingly being used in advanced non-colorectal GI cancers such as biliary, pancreatic and esophagogastric cancers. More prolonged therapy has al...
In what scenario would you recommend induction chemotherapy prior to chemo-radiation in head and neck cancers and what would be the preferred regimen?
The use of a sequential approach to treating locally advanced SCC of the head and neck is not generally recommended since three studies from Spain, the Dana Farber Cancer Institute, and the University of Chicago failed to demonstrate a survival benefit from three cycles of TPF (platinum, paclitaxel/...
What adjuvant endocrine therapy would you recommend for a male patient with HR positive breast cancer and history of DVT/PE?
For a male patient with Breast Cancer, with a history of DVT/PE, I would prefer to avoid tamoxifen and would recommend an aromatase inhibitor (AI) with a gonadotropin-releasing hormone (GNRH) analog for 5 years.The rationale of adding GNRH analog (e.g goserelin) is that the use of AIs will lead to a...
How would you approach a cT4 cN2 (22 cm in size) TNBC that shrank to 9 cm with KN-522 regimen but remains inoperable at the end of treatment?
This sounds like a tough situation. I will offer up an opinion but I know others will have their thoughts and more than one is important here. Obviously, this person is at very high risk to have occult metastatic disease. However, I think this biology is also interesting. For a tumor to have reached...
How does the presence of MMR deficiency affect your decision to treat with 3 versus 6 months of adjuvant chemotherapy in high risk stage III colon cancer?
For stage III dMMR colon cancer patients, oxaliplatin-based adjuvant chemotherapy should be offered as standard of care based on meta-analysis and fluoropyrimidine-only adjuvant chemotherapy is not beneficial (Jin and Sinicrope, PMID 33467526. Cohen et al., PMID 33356421). For high risk stage III co...
In SIADH due to malignancy, do you prefer to use free water restriction or salt tablets?
Fluid restriction is usually the first line measure in chronic SIADH. Salt tablets only work at high doses, as SIADH is a water, not a salt problem, and you improve sodium only minimally. Tolvaptan is a very powerful drug, but, as per the package insert, must be started in an inpatient setting. Addi...
What systemic therapy would you recommend for axillary recurrence of triple negative secretory breast cancer previously treated with mastectomy alone?
The type of systemic chemotherapy for locoregional recurrence of triple negative breast cancer is not standardized. Based on the CALOR trial, the dealer's choice of systemic chemotherapy reduced the risk of breast cancer recurrence specifically in triple negative breast cancer. The patient has not r...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
How would you work up and manage persistent lymphopenia in an asymptomatic patient?
Simple answer: refer to an immunologist, as this degree of lymphopenia is quite likely to represent a serious immunodeficiency. I would also send a next generation sequencing panel of immunodeficiency/immunoregulatory genes to be in process while awaiting the immunology consultation. Long answer (fr...
What is the appropriate time to initiate adjuvant chemo/endocrine therapy for premenopausal ER/PR+, HER2 negative early stage breast cancer with moderate Oncotype following breast conserving surgery?
I would think there is a reasonable window for the chemotherapy to start (which should be given first), perhaps up to as late as 10-12 weeks post op (if it has to be delayed although rare to need to wait that long). Most of the time, we have made the decision to use chemotherapy and have all the nec...