Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with a history of treated stage II seminoma with rising bHCG while on surveillance, do you routinely recheck the bHCG with a different assay?
In this setting, it depends a lot of the confidence you have in the treatment and the degree of HCG elevation. It also depends to some degree on whether the patient had an HCG elevation when he presented with stage II disease. In most of these cases these are very low level HCG elevations that bounc...
In which patients would you recommend extending adjuvant AI-based therapy beyond 5 years?
Several keenly awaited trials were presented or published last year. The MA17R looked at extending AI for 5 more years after nearly 10 years of anti-estrogen therapy (5 of which was with an AI). It showed a significant benefit in preventing contra-lateral breast cancers. These are patients who toler...
Do you routinely send Oncotype Dx on ER positive tumors with node positive disease?
I believe that the intrinsic biology of the tumor is more important than the lymph node status in determining prognosis and potential chemotherapy benefit. Given this, I do use molecular assays for node positive disease with caution. Based on a 2010 Lancet Oncology paper in which tissue blocks from ...
How do you manage immune-related toxicity from checkpoint inhibitors that is refractory to initial steroid therapy?
Consensus guidelines recommend the use of steroid therapy for immune related adverse events irAE, and fortunately most toxicities (with the exception of endocrinopathies) are reversible. No prospective data exists on the management of irAE, including steroid refractory irAE. In most cases, we use in...
Would you continue immune checkpoint inhibitor therapy in a metastatic NSCLC patient with CNS failure if the systemic disease is otherwise controlled?
Great question with limited data to give a "correct answer." I have seen CNS response to checkpoint inhibitors, but I do not expect CNS response from it. In my practice, if I saw truly isolated CNS failure with good systemic control, I would continue checkpoint inhbibitory therapy as long as it was ...
Do you routinely add anti-hormonal therapy to HER2 directed therapy in a patient with ER+ HER2+ breast cancer?
That is my usual practice.As soon as the cytotoxic part of chemo is over,patient would go on AI. I consider their long term cure and the fact that HER 2 has been countered effectively places even more importance on appropriate Hormonal strategy for cure.
What is your approach to treating metastatic prostate cancer with primary resistance to GnRH analogues or early CRPC?
There is no one correct answer for every patient. In general, patients who are primarily resistant to GnRH or who develop early CRPC and who have not received docetaxel in the hormone-sensitive setting, would be good candidates to receive docetaxel. For those who are elderly or frail, I would consi...
When do you consider local therapies (i.e. TACE) in patients with intrahepatic cholangiocarcinoma who do not tolerate or respond to chemothearpy or who are not surgical candidates?
The treatment of choice would be EBRT, ideally delivered to ablative doses or at least over 80 BED (Tao et al., PMID 26503201).For LC and OS benefits. This is an NCCN based recommendation based off of retrospective and single arm prospective (Hong et al., PMID 26668346) data. Two year LC 94% of IHCC...
How would you manage a patient with surgically resected T3N1 NSCLC who is found to have one small brain metastasis on staging MRI?
For adjuvant chemotherapy, this is a difficult question for which there is no evidence-based answer, really. The "textbook" answer is that this is metastatic disease, and adjuvant therapy has only been proven for early stage disease. However, since there is still a reasonable chance of a cure after ...
Is there any data to support to use of Brentuximab in the up-front setting in the treatment of Hodgkin lymphomas?
Currently, Brentuximab vedotin is only approved in Hodgkin lymphoma 1) following failure of 2 multi-agent regimens or ASCT and 2) for post-ASCT maintenance. However, there are several ongoing phase II and III trials in both the US and EU examining Brentuximab vedotin in the up-front setting. The lar...