Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When do you recommend a breast MRI for breast cancer surveillance?
MRI is a routine part of the work up (this would not be screening) for women presenting with axilary nodal disease and occult primary. In the era of MRI the incidence of so called occult primary has gone down becuase of higher sensitivity of MRI As far screening is concerned, it is approved for high...
What is the best way to discuss an early palliative care referral with a patient?
Patients (and providers) often struggle with the assumption that palliative care implies end of life care. While that is true in many cases, if you can overcome this false assumption, your patients can benefit. I often explain that palliative care like this: Palliative care serves as an extra set of...
Based on the data from the MA. 17R trial, would you re-start an AI in post-menopausal women who stopped therapy after 5 years?
There is no single answer here. The MA17R trial raises the question but doesn't directly address it. That said, the risk is of recurrence is ongoing so readdressing the benefits of additional therapy is quite reasonable. Important considerations include duration of time off therapy, side effects exp...
For male patients with invasive ductal carcinoma s/p unilateral mastectomy, subsequently found to have a BRCA mutation, should a prophylactic contralateral mastectomy be performed?
As is often the case in rare situations, there is no data to guide decisions. While men with breast cancer are more likey to have BRCA mutations, the risk of breast cancer in men with known mutations is substantially lower than in women with the same mutation. We have not routinely offered bilateral...
For castration-naive metastatic prostate cancer patients who you plan to treat with LHRH agonist monotherapy, how long do you treat with an anti-androgen therapy prior to and after initiating the LHRH-agonist?
I only use bicalutamide prior to starting LHRH agonist in patients with high risk of spinal cord compression or urinary obstruction. I will start bicalutamide for 7 days then start LHRH agonist therapy. In all other patients, I start LHRH agonist without combination with anti-androgen therapy.
Should ovarian suppression be recommended to premenopausal ER/PR positive patients?
The SOFT trial (https://www.ncbi.nlm.nih.gov/pubmed/25495490) found an improvement in DFS for combined ovarian suppression + AI compared to tamoxifen alone (the OA + Tam group was intermediate). While the overall results were positive, I think putting the results in practice requires looking at the ...
Do you routinely offer AR-v7 testing to determine whether to treat with chemotherapy versus enzalutamide or abiraterone in metastatic castration resistant prostate cancer?
The short answer is no, not yet, and not outside of a research study. AR-V7 testing using a CLIA approved circulating tumor cell (CTC) assay, either Qiagen-Hopkins using the Adnatest RT-PCR platform or the EPIC-Genomic Health protein assay, appear very promising as negative predictors of the clinica...
What adjuvant treatment would you recommend for stage III colon cancer in a patient >75yo but with a good performance status?
As is often the case, I'd have to say "it depends". If the patient had stage IIIA disease for which the survival curves are better than IIB and comparable to IIA patients, I'd be inclined to offer capecitabine alone (providing no other poor risk factors such as insufficient nodal count, poorly diffe...
Do you offer somatostatin analogues (eg lanreotide, octreotide) to asymptomatic patients with metastatic, nonfunctioning, well-differentiated enteropancreatic neuroendrocrine tumors?
I do use SSA in non-functional NET because of the clear PFS benefit observed. There is a difference between whether a drug may have OS benefit in a particular setting vs whether it is possible to demonstrate it in a clinical trial. Please see our position paper:Future directions in the treatment of ...
For a patient with metastatic urothelial cancer who has progressed on platinum-based chemotherapy, do you test for tumor PD-L1 expression prior to choosing atezolizumab as second-line treatment?
Currently, atezolizumab is the only drug FDA approved for treatment of patients with metastsatic urothelial cancer progressive despite first-line platinum based chemotherapy. Prior to the approval of atezolizumab, commonly used agents were taxanes or pemetrexed based on small to moderate sized singl...