Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred first-line therapy for patients with newly diagnosed intermediate- or poor-risk metastatic clear cell RCC?
For intermediate and poor risk advanced clear cell renal cell carcinoma, combination therapy is the standard of care with 4 different regimens showing an improvement in overall survival vs sunitinib: nivolumab/ipilimumab, pembrolizumab/axitinib, cabozantinib/nivolumab, and pembrolizumab/lenvatinib. ...
When can tamoxifen be safely resumed after pregnancy?
If a patient is breastfeeding tamoxifen is not recommended since its excretion into breast milk is not known and that it has been shown to inhibit lactation. This is based on 2 published trials. Given the risk of venous thromboembolism (VTE) it should likely not be restarted during the postpartum pe...
What is your preferred approach to therapy in transplant ineligible multiple myeloma initially treated with CyBorD owing to acute renal failure, after achieving a VGPR (+IFE alone) with continued mild-moderate renal impairment?
After completion of initial treatment, our practice is to offer patients maintenance therapy with Revlimid based on the meta-analysis of Revlimid maintenance done in patients following autologous stem cell transplant. This includes patients who have not had lenalidomide upfront. Using maintenance le...
What is your preferred first line therapy for advanced NSCLC with an EGFR activating mutation?
My current off-protocol approach is osimertinib as a single agent, though combining osimertinib with bevacizumab is being tested in an interesting clinical trial. The bev-erlo combination trials are very small with small hints of a survival benefit, but definitely improved progression-free survival....
What is your systemic therapy approach to women with isolated local recurrences of hormone-receptor positive breast cancer?
I will assume this case involves a chest wall or other local recurrence. In this case, it depends on whether the tumor is resectable. Based on the CALOR trial, wide resection, XRT (if not previously done), and anti-hormonal therapy would be the way to go. I would probably try to add a CDK4/6 inhibit...
Is it safe and/or necessary to combine osimertinib and carboplatin/paclixel for a patient with stage IV EGFR mutated NSCLC and advanced ovarian carcinoma?
This is a tough situation and a lot depends on the status and urgency of the ovarian cancer and whether surgery is planned for it. I would not combine the chemotherapy and osimertinib simultaneously for sure. There are several studies that show the combination of chemo and TKI is not as good as TKI ...
Do you recommend sending Oncotype for bilateral synchronous primary ER+ breast cancers?
Yes I would recommend OncoType Dx for bilateral synchronous primary ER+ breast cancers. A couple of studies, although with a small sample size, have looked at this. The first one by Karsten et al (Ann Surg Oncol. 2016) showed only a 67% concordance rate for recurrence score by Oncotype Dx for synchr...
How would you approach a young patient with a prior ER+ HER2- breast CA now local recurrence that now has Her2 positive disease?
For Her-2 positive disease, I would definitely choose chemotherapy with anti Her-2 agent(s). With Her-2 positivity and a young age, the patient is at high risk for recurrence which can be significantly reduced by the addition of anti Her-2 agents to chemotherapy. Although this is a local recurrence,...
For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?
The 5-year loco-regional failure rate in RTOG 0236 was 38%, underscoring that there is considerable need for identifying a post-SBRT salvage strategy for these patients; there are only anecdotal reports in the literature as to how to best manage these patients. Our historic approach when the failure...
How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?
This is very different from colon cancer with a solitary recurrence after a long disease-free interval. In this case, before considering any local therapy, I would treat with a course of systemic therapy to establish favorable disease biology. The vast majority of patients with recurrent, oligometas...