Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider offering adjuvant chemotherapy to a patient with HR+, Her2- T1c disease with negative axillary lymph nodes, but with a positive intramammary node?
Yes, I would consider adjuvant chemotherapy for this node-positive breast cancer. Yes, the emerging evidence is suggestive that Oncotype DX is as useful in node-positive as in node-negative breast cancer for determination of prognosis and probably decisions regarding indications for chemotherapy. Ga...
Would you continue consolidation temozolomide for more than 1 year for a patient with grade 3 anaplastic astrocytoma, after gross total resection and daily temozolomide+EBRT?
Thank you for the question.The short answer is, "no". There is no data that adjuvant chemotherapy beyond 12 months improves outcomes. The temozolomide is usually very well tolerated, but it is associated with bone marrow injury with myelodysplasia or leukemia as risks. So, in general with no upside,...
Do you use Oncotype to determine the benefit of adjuvant chemotherapy in a male patient with breast cancer?
While there are fewer data, and no randomized data, what exists suggests that male breast cancer is comprised of a similar range of biologic entities, although the distributions may differ a little from female breast cancer. The question is timely; a recent JCO article (Massarweh et al, JCO 2018), e...
Would you use enzalutamide concurrently in combination with radium-223?
In ERA223, men with asymptomatic to minimally symptomatic, chemotherapy-naive, metastatic castration-resistant prostate were randomized to receive either radium-223 OR placebo (6 cycles), administered concurrently with abiraterone acetate/prednisone. In December 2017, the independent data/safety mon...
How would you approach management of a large retroperitoneal mass that shows seminoma on biopsy?
Cure rate should be 90-95% with BEP X 3 ( EP X 4 if over age 50) . No need to consider a mixed tumor. Postchemo, he with be in P.R. and would then just observe residual mass with serial CT scans.
Do you ever consider alternate dosing strategies for hormone directed therapy in breast cancer patients who cannot tolerate these drugs despite other supportive care strategies?
When a patient has not tolerated other supportive care strategies I often tell patients to stop for a week and see if the symptoms resolve. Then have them re-start very slowly - sometimes a 1/2 a pill every other day for a week then gradually up to a pill a day. There is no data that supports this a...
Do you treat patients with metastatic renal cell carcinoma who progress on first-line TKI with single agent nivolumab or the combination of nivolumab plus ipilimumab?
This is an interesting and timely question that clinicians will face. Although data for nivo monotherapy in the front line is sparse, it is clear to me that the combo has more activity than nivo monotherapy based on ORR and CR rate. It also carries more toxicity. One approach would be to start patie...
Are there subsets of patient in which you would choose chemotherapy+pembrolizumab vs pembrolizumab monotherapy in metastatic NSCLC?
My take on what to do in the >50% PD-L1 patients from an unapologetic cross-trial comparison of KEYNOTE-024 and the 50% subgroup of KEYNOTE-189: mPFS: 10.3 in KN24, 9.4 in KN189PFS at 12 months: 48% in KN24, 45% in KN189OS at12 months: 70% in KN24, 73% in KN189 Thus, I think chemo does not add anyth...
Is there a situation where you would use a purine analogue in combination with rituximab for the frontline line treatment of normal variant Hairy Cell Leukemia?
This is an excellent question, and I was assisted in this answer by Drs. @Dr. First Last and @Dr. First Last who are both hairy cell leukemia experts since there is really not a lot of trial data to guide this answer. There is limited data for the addition of rituximab in the frontline setting in vH...
For patients with high-risk metastatic castration-sensitive prostate cancer who have completed upfront ADT + docetaxel, would you consider starting abiraterone or enzalutamide in addition to ADT while the disease is still castration-sensitive?
No. In patients with castration-sensitive disease on ADT who have completed six cycles of docetaxel as per the CHAARTED data (Sweeney et al. NEJM 2015), there is no good evidence that adding abiraterone after docetaxel while still castration-sensitive is warranted. Abiraterone has potential harm and...