Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend sorafenib as an adjunct to liver targeted therapy in patients with hepatocellular carcinoma who are awaiting liver transplant?
There is not a clearly defined role for adjuvant sorafenib following locoregional therapy for HCC. The two main prospective randomimzed trials that inform this recommendation are:- The SPACE trial (Lencioni et al, J Hepatol 2016) -- no improvement in TTP when DEB-TACE was followed by sorafenib vs pl...
What is your approach to pre-menopausal or male breast cancer patients on adjuvant tamoxifen who develop a DVT, in the absence of other risk factors for thromboembolic disease?
The treatment of male breast cancer is similar to premenopausal female breast cancer with respect to endocrine therapy. The 2 acceptable options for treatment are, therefore, either Tamoxifen or Aromatase Inhibitors + GNRH agonists. In patients with DVT, I would favor switching from Tamoxifen to AI+...
Is there evidence of clinical benefit to proceeding with partial pleurectomy / decortication over palliative chemotherapy with BSC (pleurex catheter, pleurodesis) in a patient with mesothelioma who is not a candidate for extra-pleural pneumectomy?
There is no compelling evidence here. The only randomized data are from the UK MesoVATS trial, reported in 2014, showed that patients with pleural mesothelioma randomized to video-assisted thoracoscopic partial pleurectomy/decortication had no difference in 1 year survival compared to those who unde...
When would you consider local ablative therapy (e.g. SBRT, surgery) for patients with oligometastatic non small cell lung cancer on immunotherapy?
Definitely would treat this exactly as I do for EGFR or ALK-targeted therapy. If the patient is doing well, and most sites of disease continue to be controlled but one is progressing I would consider local ablative therapy. That being said, I just had a patient doing well with a CR on ipi-nivo for ...
What strategies do you employ to mitigate mucositis related pain during the treatment of head and neck cancer?
The bottom line is there is no magic bullet that works well. I start Glutamine a week before and throughout the duration of the treatment. It seems to delay the onset. I use custom made mouth pieces to reduce dental scatter if possible--that will reduce mucositis I start with over the counter analg...
What is your approach to patients with locally advanced triple negative breast cancer with residual disease at the time of surgery?
These patients remain at very high risk for metastatic recurrence and therefore should receive adjuvant chemotherapy with capecitabine as standard of care, radiation therapy, and considered for participation in the following adjuvant clinical trials: (1) SWOG S1418 (pembrolizumab versus observation)...
How do you approach non-metastatic castration-resistant prostate cancer?
The two recent placebo controlled trials comparing apalutamide and enzalutamide in M0CRPC (SPARTAN and PROSPER) have shown sizeable and consistent effects on various outcome measures, clearly met the primary study endpoints and hence satisfied FDA regulatory criteria for drug approval in this space....
Is there a preferred neoadjuvant chemotherapy regimen for a marginally-resectable, dedifferentiated, MDM2+ liposarcoma?
There is no evidence to support neoadjuvant chemotherapy for RP DDLPS outside of a clinical trial. The STRASS trial suggests a role for pre-op radiation for this subtype of RP sarcomas, but not other histologies. As always, cases like this should be discussed in multidisciplinary sarcoma tumor board...
How do you approach isolated recurrence in a para-aortic lymph node following definitive radiation for localized prostate cancer?
This is a challenging situation with no data to guide therapy; it is not unreasonable to pursue novel PET imaging (PSMA on trial, fluciclovine) to ensure there is no evidence of other sites of metastatic disease. The treatment of oligometastatic disease continues to evolve. In this situation, I woul...
Now that there are three FDA-approved PARP inhibitors for use in ovarian cancer (niraparib, rucaparib, olaparib), how do you decide which one to use?
One, niraparib is only approved for maintenance after treatment of platinum sensitive recurrence. Olaparib and rucaparib are approved for treating active, measurable disease. Olaparib for germline BRCA mutation carriers after 3 prior therapies, rucaparib for treating patients with germline or somati...