Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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 ...
Which systemic therapy (if any) do you offer premenopausal women with a second TNBC local resectable recurrence and an extensive chemotherapy history?
Patients with locoregional recurrence definitely benefit from repeated chemotherapy for sure (as shown in CALOR trial and our own experience). The question here is after exhausting anthracycline and taxane-based therapy as most patients would have been already, what might be the best regimen? The f...
How do you approach the treatment of ITP in a pregnant patient who did not respond to prednisone?
We usually stay away from dex because of the toxicity and use the absolutely smallest dose of prednisone we can. Usually, unless the count is very low, I start at about 20mg since we’re just trying to get the count up not get a CR. We manage a lot of patients with IVIg alone, but it can get expensiv...
Would you consider 177Lu-Dotatate (Lutathera) in patients with midgut neuroendocrine carcinoma after treatment with a somatostatin analog but with Ki67 >20%?
PRRT with Lu-177 DOTATATE can certainly be considered in patients with well-differentiated G3 NETs. The expected outcomes are not as favorable as with G1/G2 NETs but better than with poorly differentiated G3 neuroendocrine carcinoma (G3 NEC) where PRRT should probably not be used at all unless in th...
How do you counsel peri- or post-menopausal women diagnosed with HR+ breast CA who wish to continue receiving testosterone supplementation?
The first question I would ask is, what symptoms is this woman treating by taking testosterone? There are a paucity of randomized trials using testosterone, in various preparations (transdermal, gel, intravaginal DHEA) in breast cancer survivors. One double placebo-controlled trial studied subcutane...