Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat HER2-equivocal breast cancer in the neoadjuvant setting?
If there is no response to AC alone, and the Her2 is equivocal, I would treat with an anti-Her2 regimen such as THP. One could also simply give traztuzumab (possibly with pertuzumab, given the new data from APHINITY to be presented at ASCO 2017) for a year after surgery similar to the HERA trial des...
How do you treat a locally-invasive, keratin-positive gastrointestinal spindle-cell neoplasm?
Treating sarcomatoid neoplasms is a clinical challenge. Approaches include treating with sarcoma-like regimens vs. treating with regimens appropriate for the site of origin. I don't think there is high level data to support a general approach but these malignancies are generally quite aggresssive an...
Is there a preferential approach for systemic therapy for triple negative breast cancer patients with leptomeningeal disease?
There are very few data on effective systemic therapies for triple negative leptomeningeal disease (LMD), mostly from case reports and small series. Much of the larger series are from unselected solid tumors and have focused on intrathecal therapy. However, it is generally recognized that systemic t...
How would you manage HER2+ GEJ adenocarcinoma that recurs as a single 1.6cm lung nodule a year after completing primary chemoradiation and esophagectomy?
It is always best with upper GI cancers to assume that there is more disease than meets the eye. Despite the presence of a single lesion on imaging, I would favor systemic chemotherapy with FOLFOX + trasutuzmab (or clinical trial) upfront. If, after 6 months of treatment, no other disease emerges, t...
Would you start immunotherapy in a patient with metastatic melanoma who is on steroids (e.g. dexamethasone for cerebral edema)?
In general immunotherapy should not be started if patients require predisone or the equivalent more than 10 mg a day.
Do you prefer rhTSH for TSH stimulation instead of thyroid hormone withdrawal when treating patients with radioactive iodine for papillary thyroid carcinoma?
There are no long-term level 1 evidences to guide the decision between rhTSH stimulation and TSH withdrawal in preparation of radio-iodine ablation. Two largest randomized studies (Strategies of radioiodine ablation in patients with low-risk thyroid cancer.N Engl J Med. 2012 May; 366(18):1663-73. Ab...
In the absence of an available clinical trial, would you favor regorafenib immediately post-sorafenib or nivolumab in patients with HCC?
At this point in time, given the continued encouraging data regarding the efficacy of immune checkpoint blockade in HCC coupled with the substantially lower toxicity when compared to regorafenib, I would choose off-label nivolumab in this particular scenario.
When do you consider for first-line atezolizumab for metastatic bladder cancer?
I see these patients in 2 groups, "cisplatin-ineligible" or "chemotherapy-ineligible”. In the “cisplatin- ineligible” group one may consider a carboplatin-based regimen (carboplatin plus gemcitabine or carboplatin plus taxol) or atezolizumab. In “chemotherapy-ineligible”, I consider both performanc...
Do you intentionally modify your breast cancer treatment plans for those on chronic immunosuppression to avoid secondary cancers?
This will usually depend on their clinical scenario. In case where I would recommend RNI, I will still recommend RNI and counsel on risks of second canceers. In patients with early stage lower risk or disease, one can consider partial breast irradiation if appropriate though I do counsel patients th...
What is the upper limits of anthracycline dose you are willing to give in a treatment-refractory metastatic breast cancer patient if the patient is responding to salvage weekly adriamycin after progression on multiple prior regimens?
I would not normally exceed 350-400 mg/m2. However, this is a tough situation in that the patient is treatment-refractory without many other great options and responding. According to the package insert, "the probability of developing impaired myocardial function based on a combined index of signs, ...