Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you routinely add eight extra rituximab doses to six cycles of R-CHOP in elderly patients with DLBCL treated with miniR-CHOP as done in SMARTE-R-CHOP-14 trial ?
I rarely give R-mini-CHOP and even when starting with that regimen I will attempt to escalate as tolerated to standard dosing in elderly patients and as such don’t see much benefit in extra rituximab.
How would you treat a patient with a history of ER+ breast cancer over 10 years ago, now presenting with an ER+ loco-regional recurrence while still on Tamoxifen?
Management of loco-regional recurrence is primarily local therapy. In this patient with ER positive LRR (HER2 negative), the first decision is to decide if this is operable. If operable, the first step would be surgical resection and consideration of local radiation. As far as systemic therapy, I wo...
What is your strategy for image surveillance for occult breast cancer after treatment?
As the are occult with all imaging including MRI there is no good strategy for imaging . Also risk of IBTR in modern era after RT in these patients is low and would just do routine annual mammogram for screening
When do you add an adjuvant bone-modifying agent in patients with history of localized breast cancer?
In my opinion this is controversial question. The meta-analysis performed by EBCTG 2016 of over 11,000 post-menopausal women, and over 6000 premenopausal women, clearly shows a benefit for the postmenopausal subset. The absolute overall survival improvement was 3.3% (p=0.002) for postmenopausal wome...
How do you interpret and manage discordant HER2 in IDC breast cancer between primary tumor and lymph nodes?
Trastuzumab and Pertuzumab have made such significant contributions to decreasing breast cancer mortality that I would give irrespective of which site (breast or axillary) is positive. Speculate as why the breast primary is HER2 overexpressing and the nodes are not are 1) falsely negative assay for ...
How would you approach treatment in recurrent, localized rectal mucinous adenocarcinoma?
Well-differentiated mucinous rectal adenocarcinoma is relatively treatment resistant. In general if there is an in-field local recurrence after prior radiation (ie: is not a marginal miss), then that is very good evidence that it is radiation resistant. There are many studies now showing that re-irr...
How do you treat a fit patient with a solitary pulmonary nodule (2cm) which is biopsy-proven small cell lung carcinoma?
Clinical stage I SCLC is vey rare but does happen. In the past this was referred to as "VERY" limited disease. We would recommend surgery, either lobectomy or just a wide wedge resection but with nodal evaluation. This patient would need adjuvant chemo with 4 courses of cisplatin (or carboplatin) + ...
When do you consider employing the 4-week dosing schedule for nivolumab?
I am beginning to see harsher toxicities while using 480 every 28 days so I have begun to revert back in those pts to 3 mg/kg every two weeks to be able to continue. So far so good but sample size too small. I am wondering whether others have opinions about this. Would be a precedent for dose reduct...
How do you counsel patients on multivitamin use during therapy?
I tell patients to stop intake of anti-oxidant multivitamins (A,C and E) at the time of consultation, and if they so wish, they can resume them no sooner than 6-8 weeks after course completion because "radiation continues to work after we're done." I simplify how radiation attacks/kills the cancer D...
Do you recommend routine dental evaluation for all patients before starting bisphosponates in patients with bone metastases?
Yes. The purpose of a dental exam prior to starting IV bisphosphonates or SC denosumab is to survey the mouth and fix any root canals, extractions, or other dental pathology prior to starting of drugs. Why? Because dental extractions during treatment with bisphosphonates or denosumab are one of bigg...