Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What do you recommend for patients who experience anorexia due to loss of appetite?
"But to eat when you are sick, is to feed your sickness."- Hippocrates A lot of preclinical work (Valter longo, Warburg etc) show he was probably right and the fact that tumors will preferentially have access to gluocse and proteins (ie PET scan-Warburg effect)I would use steroids (dexamethasone or ...
Do you repeat the comprehensive BRCA analysis (like Myriad) in "at risk patients" with a positive family history, who tested negative for BRCA1 and BRCA2 deleterious mutations 10 years ago?
Yes.
How do you treat patients with early-stage ER+/Her2- breast cancer who recur years later after definitive therapy and hormonal therapy?
There's a lot of nuances to this question. What's the disease burden? Is there considerable visceral disease? What is the performance status of the patient? And finally, patient preference? If there is considerable visceral disease, I do consider single agent chemotherapy for a few cycles, and very ...
What is your approach to the initial treatment of metastatic melanoma patients with NRAS mutations?
The incidence of NRAS mutations in the metastatic setting has been reported in up to 15-20% of patients. There are currently no FDA approved agents specifically for NRAS mutated patients who progress after immunotherapy. Some studies have shown these patients may have better responses to first line-...
In what situation would you check receptor status (ER/PR/HER2) on more than one lesion in a multifocal breast cancer?
This is should be performed when there is a discordant response to therapy. For example, a patient with multifocal HER2 positive breast cancer has tumor progression through neoadjuvant HER2 directed therapy, it is reasonable to re-check receptor status. Another instance may be considered when one le...
How are you planning to use Mammaprint for the management of locally advanced ER+ breast cancer at clinical high risk of recurrence based on size and up to 3 lymph nodes?
This is an interesting question. I am going to use Mammaprint in the adjuvant setting for patients with high risk of recurrence for tumors of any size and for 0-3 LN positive. These were the criteria used in the MINDACT study, and the 5 year distant DFS in these patients was 95% with endocrine thera...
For metastatic NSCLC patients who are started on first-line platinum doublet chemotherapy and are subsequently found to have an EGFR exon 19 or 21 driver mutation, do you switch to an EGFR TKI immediately once the mutation is detected or do you wait until progression on chemotherapy?
It depends on the response and toxicity of the chemo. If patient is in first 2 cycles and responding without out much toxicity I complete 4 cycles and then switch more or less as maintenance. If patient is not responding or having unacceptable toxicity, I switch right away. I have two patients on er...
How do you manage aromatase inhibitor- associated musculoskeletal syndrome (AIMSS) symptoms in post-menopausal breast cancer patients?
Available published data suggests that switching from one AI to another, does help to reduce AIMSS. This strategy is associated with improvement in AIMSS about 50% of the time (in published literature). From personal experience, letrozole tends to cause the most symptoms since from pharmacologic sta...
How do you decide when to refer a patient with metastatic renal cell carcinoma for cytoreductive nephrectomy?
Although dated, two large randomized trials showed a nearly 6 month OS advantage with debulking nephrectomy in the cytokine era, and thus my opinoin is that debulking nephrectomy is the standard of care in appropriately selected patients. The phase 3 data and modern retrospective analyses in the TKI...
For women with metastatic HER2 + breast cancer who achieve a complete response, how long do you continue on HER2-directed therapies?
In nearly all cases, I would continue therapy until progression or unacceptable toxicity. Multiple studies have found an improvement in PFS and.or OS by continuing trastuzumab (or other HER2 inhibitor) after progression on trastuzumab.. Ask yourself this.....if continuing BEYOND progression is helpf...