Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you modify your initial treatment for a patient with de novo metastatic HR- HER2+ breast CA who has cardiomyopathy at baseline (EF < 35)?
Fortunately, the incidence of cardiotoxicity with the combination of a taxane, trastuzumab, and pertuzumab is very low, and thus I would be comfortable starting with this treatment (preferably with weekly paclitaxel) and monitoring her with periodic echocardiograms (every 4-6 cycles, in the absence ...
Should patients receive thrombophilia testing in the setting of a provoked VTE secondary to hormonal therapy/OCPs?
Given that oral contraceptives are considered a provoking event (Ortel et al., PMID 33007077), ASH Choosing Wisely guidelines recommend against thrombophilia testing since the recommended duration of anticoagulation is only 3 months. (Hicks et al., PMID 24307720 & Hicks et al., PMID 25472968).
Is there a role for adjuvant systemic therapy (in addition to adjuvant radiation) in an early-stage, resected cutaneous angiosarcoma of the head/neck?
Angiosarcomas have a high rate of local (or distant) recurrence, but with all tumor resected and if there were wide surgical margins then radiation may be sufficient for a small superficial tumor, followed by close surveillance. If there is a recurrence, then our practice is to give neoadjuvant chem...
How is ESR used in the clinical staging/risk classification of classical Hodgkin Lymphoma in pediatric and adult patients?
There has not been a consistent initial risk classifier for childhood Hodgkin Lymphoma (in contrast to the IPS used in adults). ESR has been used to follow patients in terms of a trend if elevated at diagnosis and that continues to be suggested by the current pediatric guidelines. Schwartz et al., (...
In a healthy patient >65 years of age with glioblastoma multiforme, what is the recommendation for temozolomide when given concurrently with adjuvant radiation therapy?
Glioblastoma (GBM) is primarily a disease of older adults. The median age of diagnosis is around 60. Many of these patients present with a host of co-morbidities that impact their performance status (PS), overlapping with GBM-related complications. There are multiple scenarios to consider when evalu...
Is it safe to deliver SBRT with concurrent immunotherapy to head and neck sites of progressive metastatic disease?
Yes, have done this many times. Constraints are hard to come by. If it is reirradiation, RTOG 3507 provides guidance, if it is never radiated you have even more leeway.
How do you modify therapy for patients with severe intolerance to imatinib in the adjuvant setting for GIST?
Either of the potential solutions (dose reduce or switch to an alternative TKI) is possible. Depending on the specific intolerance, it would be reasonable to try a dose reduction. If the patient still cannot tolerate the imatinib and the patient is a high risk, then sunitinib may be better tolerated...
How long would you keep a patient on endocrine/dual anti HER-2 therapy after resection of a late (>5 years) oligometastatic recurrence of ER+ HER2+ breast CA?
I have struggled with this a few times. The handful of times I have discontinued her 2 directed treatment, there has been recurrence within a year and then it took chemotherapy plus her 2 directed therapy to achieve remission. It is now my practice to continue endocrine+her 2 directed therapy till p...
For persistent PSA elevation after prostatectomy, would you recommend salvage radiation if pathologically negative nodes, but regional and non-regional lymphadenopathy on PSMA PET?
While based on classical staging methods, it appears that he would fulfill the criteria for salvage RT with a persistent PSA, it sounds like this patient has M1a disease by advanced imaging (possibly at presentation). I think that it is very unlikely that he would gain any meaningful benefit from ad...
How would you treat oligometastatic kidney cancer in a young, fit patient with recurrence <6 months after nephrectomy?
This is a good question. Short time to recurrence of mets would generally indicate more aggressive biology i.e., the mets aren't really oligo and other mets are lurking. Having said that, careful review of prior scans may reveal that the metastatic sites were present prior to being fully recognized ...