Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat fit patients with metastatic adenocarcinoma of colon who have progressed on at least 2 prior lines of standard chemotherapy?
The answer to this question depends on the patient's molecular diagnostics and prior therapy. I'll assume FOLFOX/XELOX-bev. If KRAS WT, I'll assume followed by FOLFIRI-EGFRi. If the patient is MSI-H, I would strongly recommend immunotherapy with pembrolizumab based on Le et al, NEJM. If MSS and you ...
How do you approach treatment options for men with germ cell tumors that relapse within 2 years of initial chemotherapy?
In general, patients who relapse more than 3 months out from initial chemotherapy will respond to platinum-based chemotherapy. I prefer TIP regimens x 2 followed by tandem transplant vs TIP x 4 but I will do the latter in patients who do not get approved for transplant or who are not medically clear...
Could a non-cirrhotic patient with a single HCC lesion measuring >5cm who is ineligible for liver transplant by Milan size criteria alone become a candidate if the tumor shrinks after TACE?
While the Mazzaferro (Milan) criteria still represent the primary basis by which HCC candidates for liver transplant are chosen, certain centers such as ours (UCSF) have studied the strategy of expanding eligibility criteria for OLT. This includes both increasing upper tumor size limits, as well as ...
Do you counsel patients on the risk of dementia following androgen deprivation therapy for prostate cancer?
No, I generally do not counsel men about this risk. The two studies from the same investigator use a data warehouse search algorithm that may not be accurate enough to fully characterize who gets Alzheimer's disease or may not be able to correct for confounding factors that may be different between ...
How to you treat patients with germ cell tumors that progress during treatment with first-line platinum-based chemotherapy (i.e. platinum-refractory disease)?
This is extremely uncommon and a common mistake is to label someone as cisplatin refractory who really isn't. I would have to see the pattern of markers over the course of treatment and be assured that sanctuary sites have been ruled out prior to formally declaring someone as cisplatin refractory. T...
How would you treat a patient with metastatic, MSI high, small bowel adenocarcinoma in the frontline setting and after first progression?
This is a really interesting question. If you prefer a more standard approach, I would recommend FOLFOX (I have used bevacizumab in some patients with this cancer, but there isn't great evidence I know of to support use). However, in an MSI-H patient, trying anti-PD-1 therapy sooner rather than late...
How would you treat a patient with metastatic colon adenocarcinoma with a HER2+ tumor who has progressed despite standard 5-FU containing regimens?
Assuming the patient has progressed on standard treatments for mCRC including oxaliplatin and irinotecan-containing regimens with the appropriate biologics, I would consider HER2 directed therapy. I generally prefer that to be on clinical trials such as MyPathway or MATCH or similar trials. Outside ...
Do you ever consider referring fit patients with NSCLC and oligometastatic disease isolated to the pleura for extrapleural pneumonectomy?
I do not believe that there is a role for EPP in NSCLC patients with pleural nodules. The morbidity of the surgery is quite high, and the chance of cure is minimal. This is not a situation for which the term oligometastatic disease is truly appropriate. On the other hand, if the patient has pain fro...
How do you approach patients with low ER positive (1 - 9%) breast cancer?
The EBCTCG meta-analysis on adjuvant tamoxifen found benefit with tamoxifen use across all subgroups of ER expression, including the low expressors (1-9%). The absolute benefit of tamoxifen may not be significantly high. In my practice, I do offer anti-estrogen therapy in such a setting, but have a ...
How do you approach the management of borderline resectable pancreatic cancer in patients with superior mesenteric artery vs vein abutment ?
This is an area where treatment paradigms are in flux. If there is no vascular abutment our usual policy is resection followed by adjuvant treatment. With the augmented response rates being seen with FOLFOXIRI and gemcitabine + nab paclitaxel there is a better chance that tumor shrinkage off of vasc...