Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What regimen would you choose for patients with breast cancer requiring adjuvant chemotherapy whose livelihoods depend on fine dexterity (such as a professional musician)?
The appropriate treatment depends on the clinical presentation of the breast cancer so that the risks/benefits of recurrence vs side effects are properly taken into account. A stage 3 TNBC would generally require a 3rd generation anthracycline/taxane regimen for optimal outcomes. A better approach w...
Would you consider maintenance therapy for patients who achieve complete response after palliative chemoradiation for metastatic distal esophageal adenocarcinoma?
There isn’t much evidence in this setting. I definitely consider chemotherapy and radiation in patients with small burden metastatic esophageal adenocarcinoma if they have significant dysphagia. Chemotherapy and radiation in the end is the most effective way to palliate dysphagia. I do however also ...
What dose regimen do you use when a women with inflammatory breast cancer is not responding to chemotherapy and needs radiation prior to surgery?
The data suggest pre op RT can convert some of these inoperable patients to surgery. I use comprehensive RT to preoperative dose of 50 Gy in 25 fractions in these patients
What is your approach to a low grade appendiceal mucinous neoplasm found incidentally at appendectomy?
If there is no high-grade component (adenocarcinoma), appendectomy is sufficient. There is no role for adjuvant therapy and no need for surveillance imaging in this setting. Low-grade appendiceal mucinous neoplasms with disseminated peritoneal adenomucinosis (pseudomyxoma peritonei) constitute an en...
How do you approach rising gastrin and chromogranin levels without radiographic evidence of disease in patients with gastrinoma that has been fully resected?
We see this scenario with some frequency - rising hormone or peptide levels in functional NETs without radiographic evidence of disease. My next step would be to get the new Ga68 DOTA TATE PET/CT - essentially a new generation octreoscan with high sensitivity and specificity. These scans often pick ...
When do you choose to give CyBorD over RVd in a newly diagnosed myeloma patient?
I only use VCd when patients are going to be inpatient for a while or the patient is unable to afford an IMiD. For patients with renal insufficiency, where time is of the essence, I recommend Velcade 1.3 mg/m2 SQ days 1,4,8,11 + dex 20 mg days 1,4,8,11 with Revlimid 5-15 mg in newly diagnosed MM. L...
Do you find the measurement of ultra-sensitive PSA provides clinical benefit in a patient with biochemical recurrence after radical prostatectomy compared to non ultra-sensitive PSA measurement?
Yes- for patients post prostatectomy uPSA should be ordered. The outcome of salvage RT is tied to PSA levels and the lower the PSA better the outcome.
Do you send Oncotype in patients with ER/PR+ breast cancer and micrometastasis in one sentinel node?
I do send a Mammaprint, as the MINDACT trial (NEJM 2016) demonstrated that women with ER positive breast cancer and 0-3 LN with a low risk profile had a 94.5% 5 year distant disease free survival with endocrine therapy alone. If high risk, I'd offer AC x 4, taxol x 12, which is my standard regimen f...
Would you offer adjuvant chemotherapy for a patient with ER/PR (+), HER2(-) breast cancer less than 5mm in size with a high Oncotype score?
I don't get genomic tests in T1aN0 tumors, in fact many times the tissue is insufficient. These patients were not reflected in the studies validating these assays, and existing data suggest they have excellent prognosis.
Among patients with anal SCC, is it reasonable to replace 5-FU with capecitabine when delivering definitive chemoradiotherapy with concurrent mitomycin C?
Yes, capecitabine can be substituted for infusional 5-FU in this setting. The NCCN guidelines include the capecitabine/mitomycin + RT regimen.