Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What systemic chemotherapy do you prefer with concurrent radiation therapy in the neoadjuvant setting for early stage rectal cancer?
In this setting, I always prefer capecitabine for the sake of patient convenience. If there is a reason I can't use it (e.g. renal insufficiency, poor compliance with oral medications), I opt for infusional 5-FU. I would only consider bolus 5-FU if the patient experienced coronary vasospasm with cap...
In view of possible equivalent efficacy of low dose abiraterone with food, has anyone had clinical experience offering low dose abiraterone to spare patients from financial toxicity of abiraterone?
The Szmulewitz study is a well done and robust pharmacokinetic study of low dose abiraterone with food. There is a well written commentary from Glenn Liu in the same issue of JCO.While the study does show pharmacokinetic equivalence, it is difficult to extrapolate comfortably to clinical equivalence...
Do you routinely offer neo-adjuvant chemotherapy for patient with triple negative metaplastic breast cancer?
I generally offer neo-adjuvant chemotherapy for all patients with triple negative breast cancer that are larger than 1cm. Triple negative breast cancer, metaplastic or not, is comprised of a large group of heterogenous cancers. These patients all need chemotherapy and giving it in the neoadjuvant se...
Would you use immunotherapy in a patient with metastatic lung adencoarcinoma, high PDL1, but had polymyositis as a presenting paraneoplastic syndrome?
I personally would not start with a PD-1/L1 inhibitor in this population. Many trials with this class of immune checkpoint inhibitors allowed patients with autoimmune histories to be included if they had not required treatment for a prolonged period of time. Given the potential debilitating nature o...
What would you choose as the second line treatment option for a stage IV EGFR mutant lung adenocarcinoma that has progressed on osimertinib?
The best choice for 2nd line treatment after progression on osimertinib depends on multiple factors. If a patient has progressive disease in only 1 area while all other areas are well controlled, you could consider local therapy (SBRT or EBRT) to that one area of progression, and continue the osimer...
How would you treat a patient with EGFR+ oligo-metastatic lung adenocarcinoma status post resection of the primary and metastatic sites?
This is a somewhat challenging question - on the one hand, the patient has metastatic (albeit "oligo" metastatic) cancer and systemic treatment with osimertinib is clearly indicated and appropriate for metastatic EGFR mutant lung cancers. On the other hand, all known disease has been resected, and t...
Are the cardiac risks of LHRH agonists also seen in patients undergoing bilateral orchiectomy for ADT in hormone-sensitive prostate cancer?
Although the true implications of testosterone suppression on cardiac risk/disease remains somewhat undefined, it is the low testosterone levels, not the mechanism of how these levels were obtained i.e. either surgical or medical castration that is the issue.
How do you approach a metastatic, intermediate grade NET of GI origin with clinically significant tumor burden?
As there is still no universal consensus around the NET nomenclature, I will start by tackling the definition of intermediate grade and use the ENETS/WHO classification of grade by proliferation status, i.e. mitotic count 2-20 per 10 high-power fields and/or Ki67 3-20% (with the higher of the two be...
How do you approach the treatment of hairy cell leukemia with inadequate response to front line therapy?
It is unusual not to achieve an excellent response, usually CR, following initial therapy with a single cycle of Cladribine. I would always make sure that the diagnosis is correct. There are other lymphoproliferative disorders which can be mistaken for hairy cell leukemia (HCL). Whenever I hear of a...
How does your approach differ when managing a "triple hit" versus a "double hit" or "double expressor" lymphoma?
Double-hit lymphoma and double-expressing lymphoma are biologically and clinically distinct entities. DHL is now classified within the WHO as high-grade lymphoma, and the majority are of germinal center immunophenotype, whereas DEL is most typically of non-germinal center immunophenotype and classif...