Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with anal squamous cell carcinoma and 5 FU induced coronary vasospasm 36 hours after starting definitive chemoradiation?
I would seek the assistance of an oncocardiologist, if available. Did the patient develop EKG changes? Troponin leak? For coronary vasospasm induced by 5FU, there is a range of severity and risk. Given that this patient only requires a second dose of 5FU, I would see if there were any possibility of...
For patients with locally unresectable/metastatic head and neck cancer who achieve complete response to chemoimmunotherapy, how do you manage their subsequent care in terms of continuing therapy vs. close monitoring?
While we do not exactly know the ideal duration of treatment for patients who are treated with immunotherapy and attain CR, it is likely safe to assume that treatment up to 2 years is reasonable. This stems from data within the melanoma literature. So, for a patient receiving chemotherapy + immunoth...
How would you treat a metastatic pancreatic cancer patient who develops symptomatic leptomeningeal disease on first line FOLFIRINOX?
This is a really unfortunate situation. There is some evidence that gemcitabine, at least, crosses the blood-brain barrier and there is at least one case report of a patient in a similar situation responding to gemcitabine/nab-paclitaxel. Given this and the paucity of data supporting other options f...
When do you offer adjuvant radiation in addition to chemotherapy for patients with high risk localized gastric adenocarcinoma who did not receive pre-operative therapy?
Would recommend starting concurrent chemo-radiation 4-6 weeks postoperatively, when the patient has recovered from their surgical procedure.The US GI Intergroup trial 0116 demonstrated improvement in both RFS and OS for gastric cancer patients at high risk after surgery (T2-4N0, T1-4N+), who were ra...
How would you treat a newly diagnosed male with metastatic HR+ breast cancer?
I would recommend CDK 4/6 with AI and GnRH analog.There's no clear evidence from studies since male breast cancer is rare (<1% of breast cancers), and most CDK studies did not include male patients. One case report was published recently by Hansra et al., PMID 31929882.FDA-approved palbociclib for m...
How do you approach treatment and surveillance of breast cancers in patients carrying germline MUTYH mutation?
NCCN guidelines do not currently recommend any increased breast cancer surveillance for MUTYH carriers. However, patients might still be eligible for increased breast screening based on family history of breast cancer which would need to be evaluated separately. Currently, this mutation does not aff...
Would you change chemotherapy in metastatic TNBC with impending cord compression but other visceral disease stable?
Assuming the symptoms that led to the diagnosis of cord compression developed while on this treatment, I would consider it progression and an indication to change treatment after the patient completes radiation (she'll have to be off treatment during radiation, anyway). Depending on her prior treatm...
How would you approach treatment in an otherwise young, fit patient with transformed AML currently in remission with a plan for transplant and was found to have an invasive fungal infection not amenable to resection upon recovery from induction?
This is an all too common problem. Firstly, "not resectable" is sometimes in the eye of the beholder. Ensure all effort is made to resect if this is isolated even if it's a brain lesion or needs a lung resection. Secondly, not all "fungi" are the same. If this is mold, you must be sure it is "not re...
Would you hold pertuzumab around the time of surgery?
There is no basis for holding pertuzumab at the time of surgery, or for other procedures for safety reasons for patients who are tolerating therapy well. However, for patients who are having significant side effects such as diarrhea that is temporally related to the administration of the drug- or is...
Would you offer further chemotherapy in the adjuvant setting after resection of an isolated liver met that developed shortly after completion of adjuvant FOLFOX for colon cancer?
This is a difficult question but is a scenario we meet from time to time in the clinic. The first question is when we say shortly after completion of adjuvant FOLFOX, what is the interval between completion of FOLFOX and the liver metastatic lesion detection? Usually, we think it is a short period ...