Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you use immune checkpoint inhibitors in patients with well-compensated liver cirrhosis?
There are essentially no good data describing the safety and efficacy of immune checkpoint inhibitors in patients with compromised organ function. The issue is complex, in that altered liver function will change protein binding of the drugs, potentially alter catabolism etc. Autoimmune hepatitis has...
How do you approach disease monitoring in patients with localized rectal cancer who have received treatment with chemoradiation?
MRI can provide useful results about tumor stage before and after re-operative chemoradiation. If tumors show a good response to chemoradiation this is a good prognostic sign. For tumors that are initially very large, another reason to do an MRI after chemoradiaiton is to see if the tumor is surgica...
How do you manage severe cytarabine syndrome in AML patients, manifesting as severe hypotension, fevers, rash, and myalgias?
The cytarabine syndrome is a well-described (Castleberry et al. (1981) Medical and Pediatric Oncology 9:257) syndrome mediated by pro-inflammatory cytokines that are associated with fever, hypotension, rash, and often renal failure. In my experience, its most severe manifestations occur when a patie...
Do you see a role for adjuvant sunitinib after resected RCC?
The role of VEGF-R inhibitors as adjuvant therapy in RCC is an evolving field. As you point out, ASSURE was negative but S-TRAC was positive. Each study has to be interpreted on it own while also trying to reconcile the different results. S-TRAC was different in that it was clear cell only, a higher...
How do you decide what to use for 2nd line treatment of liver-predominant metastatic neuroendocrine tumor that has progressed on a somatostatin analog?
Following progression on an SSA, there are a number of options and they differ depending on primary site and whether or not the tumor is functional (ie. secreting a hormone that causes symtoms of hormone excess. I will outline some scenarios below:1) For patients with non-functional liver-predominan...
How would you approach the management of a patient with oligometastatic NSCLC characterized by a LUL mass and a solitary adrenal metastasis, assuming a good performance status?
Induction chemotherapy (platinum-doublet x3 cycles) followed by lobectomy, mediastinal lymph node dissection, and adrenalectomy if no progression after induction chemotherapy.Reference: Gomez DR et al, Lancet Oncology 2016
What is the role of platinum agents in the treatment of metastatic breast cancer in patients with BRCA mutations?
The TNT study compared taxanes versus carboplatin in triple negative breast cancer and did not show a difference in response rate. However, amongst BRCA germline mutation carriers there was a significantly higher response rate amongst women with BRCA mutations. Therefore, platinums are good options ...
For patients with RCC who respond to PD-1 blockade, do you ever discuss stopping treatment?
It has only been a year since nivolumab was approved for the treatment of metastatic renal cell carcinoma (mRCC). In the absence of long term follow up data, especially in the real world setting, it is difficult to conclude whether stopping treatment with nivolumab in responding patients is appropri...
For the rare NSCLC patient who achieves a CR on anti-PD-1 or PD-L1 therapy, do you consider either spacing out dosing intervals or offering treatment breaks?
Taking a break is always worth discussing in situations like this. Often the patient and doctor are a bit reluctant (understandably), but in the absence of data from the pivotal trials to date it seems reasonable for some.
How do you interpret the results of the ACT II trial in terms of the choice between cisplatin and mitomycin in the treatment of anal cancers?
As you know, the ACT II conclusion was that a 5-FU/cisplatin regimen did not improve outcomes and had similar toxicities (less hematologic toxicities) when compared to the standard of care 5-FU/MMC. The RTOG 9811 trial demonstrated worse DFS/OS with induction followed by concurrent 5-FU/cisplatin. B...