Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the role of salvage radiation therapy in patients with locally recurrent Hodgkin lymphoma after an autologous stem cell transplant?
How best to employ radiation therapy in patients with Hodgkin lymphoma (HL) who progress after autologous stem cell transplantation (ASCT) is not entirely clear. Often such patients are considered for an allogeneic stem cell transplant, typically utilizing a non-myelablative conditioning regimen. Th...
Would you send a lung cancer patient for genetic counseling/germline mutation testing if they are harboring mutations in NGS with variation allele frequency between >=50%?
EGFR T790M mutations can indeed be present in the germline and represent a heritable risk factor for lung cancer. The two families I have identified were initially found by tumor genetics showing a 50% allele frequency for T790M in an untreated patient's tumor, usually with an EGFR exon 19 or L858R ...
Is there any data to quote possible benefit of endocrine therapy in an elderly woman with low risk breast cancer who is refusing primary surgical treatment?
Yes, there are primary neoadjuvant endocrine trial versus surgery in Cochrane review (Morgan et al., Surgery versus primary endocrine for operable primary breast cancer in elderly women (70 years old); Cochrane Database Syst Rev 2014;5:1-40). The randomized trials used tamoxifen. The bottom line is ...
Should durvalumab consolidation still be offered to Stage III NSCLC patients with PD-L1< 1%?
This is an extremely important question, but basing therapeutic decisions on this post-hoc, exploratory analysis is fraught with hazard. Still, the absence of OS benefit in this cohort (the HR heads in the wrong direction) gives me pause. For those with PD-L1 expression of 1% or higher, I enthusiast...
Is it acceptable defer or forgo biopsy and to start androgen deprivation therapy in an elderly, fragile patient with PSA in the 900s and evidence of bone metastases?
These questions come up regularly in practice. There seem to be two questions here.One is the acceptability of starting therapy for prostate cancer without biopsy confirmation. There is a small single institution retrospective evaluation and positive predictive value of PSA in diagnosing PCa. With a...
Are there any circumstances you would not recommend sentinel lymph node biopsy in a breast cancer patient?
It is clear that we are moving away from aggressive axillary surgery for patients with minimal axillary disease given that no survival or axillary recurrence benefit (ACOSOG Z11, AMAROS) and increased risks of functional morbidities have been identified with completion axillary dissection. Naturally...
When do you treat oligometastatic triple negative breast cancer aggressively?
This issue is complicated by the fact there is no standard definition for oligometastatic breast cancer. A study by Kobayashi et al. looked at a series of oligometastatic breast cancers defined as 1-2 organ sites involved with less than 5 metastases. Consolidative local therapy in chemo responsive p...
Is there a role for checkpoint inhibition in patients with advanced, high PD-L1 expressing, chemotherapy-refractory thymoma?
I agree with @Dr. First Last. For now, I would not treat thymoma patients with immune checkpoint inhibitors outside of a clinical study, based on the serious and frequent immune-related adverse events seen in this population as detailed above. There are several single agent chemotherapy options for ...
How do you manage a newly diagnosed locally advanced ER+/HER2- breast cancer with synchronous diagnosis of metastatic melanoma?
When dealing with two concurrent malignancies you need to look at the overall prognosis for both of them to determine the best course of action. If the melanoma was oligometastatic and resected to NED or had a complete durable response to immunotherapy then one could consider more aggressive curativ...
How do you manage elderly women with high-risk HER2 positive disease with baseline low ejection fraction?
Aside from avoiding use of an anthracycline, I would treat them with a chemotherapy regimen appropriate to their disease stage and overall medical condition - which may mean using a less intensive or shorter regimen than I would in a younger, fit patient with the same stage of HER2+ disease - plus t...