Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your choice of endocrine therapy (if any) for a premenopausal woman with an ER positive 2nd DCIS in ipsilateral breast who has completed 5 years of tamoxifen after lumpectomy of 1st DCIS?
The original DCIS was 10 years ago and Tamoxifen was given to prevent a local recurrence and a new primary. We have data that tamoxifen can have beneficial effects for at least 5 years after discontinuation. GIven that this is the second primary the first thing would be to check her genetics. THat m...
Can the CDK 4/6 inhibitors be used in patients with metastatic breast cancer to the bone marrow?
CDK 4/6 inhibitors do cause cytopenias, especially neutropenia in patients with metastatic breast cancer. Palbociclib and ribociclib cause neutropenia more frequently, and more frequently severely than abemaciclib. This would be my primary concern in treating patients with breast cancer metastasis t...
How would you treat metastatic malignant peripheral nerve sheath tumor in a patient who received adjuvant Adriamycin ( 240 mg/m2) 10 years ago for breast cancer?
Ifosfamide+Etoposide has activity in MPNST and could be considered in a patient with prior doxorubicin. In general MPNST is treated as other metastatic soft tissue sarcomas. There is still the possibility of giving a doxorubicin containing regimen such as doxorubicin+olaratumab for a couple cycles a...
Is there any evidence for efficacy of using a PARP inhibitor in metastatic triple negative breast cancer who progressed on platinum therapy with BRCA-2 variant of unknown clinical significance on molecular testing?
The main recent PARPi trials (OlympiAD, Embraca) enrolled women with known or suspected pathogenic germline mutations so the efficacy in true VUS patients is not known. There are efforts to try and predict the effect of VUS mutations on BRCA function (Woods et al Genomic Med 2016), but we don't know...
Is there a role for any non-cisplatin based adjuvant therapy or radiotherapy (in absence of platinum sensitizer) for muscle-invasive, node-negative bladder cancer after radical cystectomy?
This is a very clinically relevant question that we often wrestle with the optimal management. In the adjuvant space, multiple investigators have looked at alternative adjuvant chemotherapy regimens for patients after cystectomy and deemed cisplatin-ineligible. The most ideal would be carboplatin-ba...
What palliative systemic treatment options (if any) may be considered for metastatic adenocarcinoma of the rete testis?
There is no known effective therapy for metastatic rete testis cancer. I presume the patient is not a candidate for resections of metastatic deposit(s). If we were seeing here we would do NGS to see if there is anything that could be therapeutically exploited. Sorry.
How do you assess the risk of cardiotoxicity from HER2+ agents?
The standard risk factors for cardiac dysfunction from Her2+ therapy are age, prior chest radiation, prior cardiotoxic therapy, baseline LVEF, and co-morbidities such as diabetes, dyslipidemia, obesity, hypertension, atrial fibrillation/flutter, and coronary artery disease. In addition to these, som...
What is your approach to women with early-stage hormone responsive breast cancer intolerant of AI's who want to remain on endocrine therapy but have contraindications to tamoxifen?
Assuming you have tried all 3 AIs along with maximal supportive care for the side effects leading to intolerance and you truly have an absolute contraindication to tamoxifen then you don't have any real proven other options in a postmenopausal patient. Sometimes the patient will quit therapy altoget...
For patients with HER2 positive breast cancer s/p neoadjuvant chemotherapy with TC-HP who did not have a complete pathological response at surgery, is there any evidence to use an anthracycline-based chemotherapy after the surgery?
There isn't large comparative data comparing giving anthracyclines vs not in non-PCR patients. In NEOSPHERE all the patients got adjuvant anthracycline after nonanthracycline therapy. It appeared that patients with a PCR did numerically better than non-PCR patients despite all getting anthracyclines...
Is there a role for retreatment with immunotherapy in patients progressing after initial treatment with immunotherapy for metastatic non small cell lung cancer and who achieve complete or partial response at two years?
The data regarding discontinuation of immunotherapy at 2 years comes mainly from melanoma studies with pembrolizumab. The data in melanoma is strong that therapy can be discontinued, and in these patients the 24-month disease free survival after discontinuation was nearly 90%. The data for NSCLC is ...