Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you use neoadjuvant chemotherapy to treat a patient with NMIBC on TURBT pathology but with CT imaging suggestive of cT3 disease?
Clinical staging in bladder cancer can sometimes be challenging and not always clear. Repeat TURBT, esp. for T1 stage is a standard practice to reduce risk of under-staging, even if MP is present. CT IVP (ideally before TURBT to avoid "stranding" effect), exam under anesthesia, and TURBT may all hel...
What is your preferred second line therapy for an HCC patient who progressed after first line checkpoint inhibitor monotherapy?
After progression on immunotherapy monotherapy, assuming the patient is still eligible for further therapy and VEGF inhibition, I will move to a VEGF TKI. While the data supports the use of lenvatinib or sorafenib in the front-line setting (REFLECT and SHARP trials), I will use one of these agents (...
How do you approach patients with a history of lymphoma in remission who are in need of immunosuppressive (e.g. TNF blockers, 6MP) or other therapies (e.g. JAK inhibitors) for autoimmune disease that have been linked with the development of lymphoma?
Dierickx et al., PMID 26384356. Yes, you can resume immunosuppression (IS) safely. If rituximab can be used for auto immune disease treatment that would be perfect.The prior treatment for lymphoma if it included rituximab would have taken care of the b cell reservoir.If high risk for recurrence of l...
Would you consider pembrolizumab for a patient with microsatellite stable stage IV colon cancer with high TMB on liquid biopsy who has progressed on all standard therapies?
The Keynote 158 study demonstrated an objective response rate of 29% in patients with MSS tumors and TMB >=10 mut/MB (Marabelle et al., PMID 32919526). FDA subsequently approved pembrolizumab treatment for patients unresectable or metastatic tumor mutational burden–high (TMB-H; ≥ 10 mutations/megaba...
How do you decide on the timing of neoadjuvant chemoRT or short course radiation for a patient with mid-upper rectal cancer with resectable liver only metastases?
Upfront multiD discussion is really essential for a case like this as I do think we need to be selective of ideal candidates. If the group consensus is to proceed along a pathway involving “curative intent” local therapies, I do favor starting with systemic therapy to establish disease biology/pheno...
Do you include bevacizumab with chemotherapy in patients with metastatic colon cancer with an intact primary tumor who have intermittent obstructive symptoms?
I agree with Dr. @Dr. First Last. If I am worried that obstruction could happen but we are not at the point where we need to pause for a diversion, I will start chemo without bevacizumab for the first 2 to 3 doses - so that we get that response that he mentions - and then I can add without being too...
How do you decide between CPX-351 and HMA + Venetoclax in treating transplant eligible AML-MRC?
I would consider CPX-351 (liposomal daunorubicin and cytarabine) in anyone who you would consider to be an induction chemotherapy (7+3) candidate. The indication is for newly diagnosed MDS/AML (AML-MRC) or treatment related MN (t-AML). Benefit is the response can be seen quicker in 1 cycle as oppose...
What is your approach to patients with malignant breast adenomyoepithelioma?
We recently published a case series and review for ADME breast tumors. (Parikh et al., PMID 33607537) No proven role for specific therapies but for malignant ADME over 2cm, there are cases of metastatic spread to lungs and brain. So we have discussed adjuvant chemo and/or endocrine therapy after com...
What is your preferred first line regimen for a patient with BRCA+ metastatic pancreatic cancer with poor performance status?
The key question here is, "Are there any data to support the use of maintenance olaparib in BRCA-mutated patients after non-cisplatin first line chemotherapy?" This question arises from the results of the POLO trial which showed improvement in progression-free survival with the use of maintenance ol...
Are there any clinical scenarios where you would recommend adjuvant docetaxel for localized prostate cancer?
This is quite a controversial topic and good for a tumor board discussion! The RTOG 0521 trial is the only trial to demonstrate a potential survival benefit with docetaxel in the adjuvant setting following radiation and in the setting of long term ADT. The absolute difference in OS at 4 years was 4%...