Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a young man with refractory AML after HIDAC induction who developed cerebellar toxicity to HIDAC and previously received doxorubicin (300 mg/m2) for lymphoma?
CLAG-M (cladribine, Ara-C, mitoxantrone, with G-CSF priming)
Do you routinely include sipuleucel-T as one of your lines of systemic therapy for metastatic castration resistant prostate cancer?
In select patients, I will use Sipuleucel-T as first line therapy for patient with early castrate resistant disease that are asymptomatic. Those that I use Sipuleucel-T I will observe them post therapy unless I see a rapid increase in PSA or other symptoms, then I will start AR directed therapy. Inc...
What is your preferred third-line treatment for a patient with metastatic renal cell carcinoma who has had progression of disease on both initial VEGFR-TKI therapy and second-line nivolumab?
My preferred line treatment is based on the patients initial experience with the 2 prior therapies. If he is a "non-responder" to a VEGF TKI and then nivolumab, my third line choice is then everolimus plus lenvatinib as mTOR inhibition is a novel approach and efficicacy is improved in combination wi...
Which PET imaging modality, if any, is preferred to work up possible nodal involvement or local recurrence in prostate cancer?
In my view, better, more sensitive imaging will transform our management of prostate cancer. Soon, I believe, maybe very soon, we'll be able to detect small volume nodal metastases and small volume metastatic disease. How to manage patients with, say, a solitary, <1 cm lymph node seen on PET will be...
What third and fourth line options do you consider for patients with pleomorphic sarcoma and a good performance status who have progressed on standard anthracycline and gemcitabine/docetaxel?
If the pleomorphic sarcoma is a UPS/MFS - immunotherapy trials would be of interest. As always, any active clinical trials of newer drugs should be considered. SOC alternatives would include Pazopanib. There is also some data (and therefore a broader indication in EU) for trabectedin.
For patients eligible for and considering active surveillance for low-risk prostate cancer, do you routinely use tests for molecular risk stratification?
I have not incorporated genetic testing into my active surveillance strategy. As yet, it is not clear how to use this information to modify the approach to AS. At this point, multi parametric MRI is far more useful, and I recommend this test to all of my patients considering AS to try to rule out th...
Is there any role for the use of cytochrome P450 2D6 (CYP2D6) testing for tamoxifen resistance in routine practice?
This is a matter of some debate. The earlier retrospective studies did show some lack of tamoxifen benefit with certain homozygous genotypes of CYP2D6, but some later, larger trials did not bear this out. Thus, the matter remains unsettled in my opinion.
In newly diagnosed metastatic non-squamous NSCLC patients, which (if any) genomic targets are you routinely testing for besides EGFR and ALK?
If KRAS, EGFR, and ALK are negative, I also evaluate tumors for ROS1 (with crizotinib now approved for this indication), MET (exon 14 skipping or amplification), HER2, BRAF V600E, RET and NTRK (mainly for clinical trial options). This is usually part of a panel of 200 or so genes. While I try to exc...
Are you routinely offering nivolumab for second-line treatment of small cell lung cancer?
What is your approach to an optimally debulked patient with Stage Ia FIGO gr 3 serous carcinoma of the ovary?
For high grade serous early stage tumors, I use 6 cycles of carboplatin/paclitaxel. This is based on data from GOG 157 (Chan et al, Gyn Onc 2010). Single agent carbo would not be standard, but can be used in elderly or frail patients. This is a complicated situation, and treatment recommendations sh...