Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you choose between regorafenib or TAS-102 in patients with metastatic colorectal carcinoma that has progressed on all prior 5-FU based regimens and anti-EGFR therapy?
Despite their FDA approval, both TAS-102 and regorafenib are equally marginal drugs in terms of their efficacy. In the world of GI Oncology, there are those of us who do and do not treat HCC; those who do have experience with sorafenib and regorafenib and find both drugs to be "tolerable". On the ot...
How do you decide on the type of ovarian suppression (GnRH agonist vs. GnRH antagonist) in premenopausal patients treated with an AI?
Based on current available literature in Breast Cancer it is premature to change to GnRH antagonist such as Degarelix. While action of onset is more rapid with Degarelix (3 days) versus triptorelin (14days) (GnRH agonist) side effects are more pronounced and efficacy data is still lacking. In the re...
In patients with stage II-III HER2+ breast cancer who were not treated with neoadjuvant therapy, without having knowledge of response to neoadjuvant therapy (i.e. pCR or not) after chemotherapy, what is your preferred adjuvant HER2 directed therapy?
I largely agree with @Dr. First Last. I am also underwhelmed by the APHINITY data and limit TDM-1 to patients with residual disease after neoadjuvant therapy that includes trastuzumab +/- pertuzumab. And, while I am sure that they exist, I have yet to see the patient to whom I would recommend nerati...
How would you manage CML first-line second generation TKI with a best response of MMR 4, but now with a loss of MMR with more than one log response loss but still in complete cytogenetic remission and mutation panel negative?
The easiest would be to repeat the test in 1 month or so. If the results show persistently increased levels, then I would monitor the patient closely. I would also review any new medications for possible drug to drug interactions. I would also review the patient's adherence, does the patient still h...
Can you use Mammaprint to decide on chemotherapy in a young patient with positive sentinel nodes if no further axillary dissection is planned to see if there is more nodal involvement?
Mammoprint is the only genomic assay with level one evidence in node positive patients. Assuming that no axillary dissection to be done suggests ACOSOG Z-11 in a lumpectomy patient. Most would agree that taking more than one sentinel node decreases the risk of false negative assays so, in a patient ...
What factors affect your decisions in in the initial management of a stage IIIB bladder cancer?
For cN+ bladder Ca, I start with induction chemotherapy aiming for 4-6 cycles (restaging initially after 3 cycles and continue to 1-3 more cycles depending on response & tolerance) since the risk of micro-Mets is exceedingly high. If a patient has a great response to induction chemo, options may be ...
How do you treat patients with sensitizing EGFR mutations who progress on osimertinib with small cell transformation, but with persistent EGFR mutation detected in the peripheral blood or tumor?
There are no studies to directly address this issue. For sure the patient needs chemotherapy with etoposide/platinum. Whether osimertinib should be continued during the chemotherapy or re-instituted after 4 cycles of EP has not been studied. I would give both.
How would you approach the management of newly diagnosed metastatic colon cancer in a patient who experienced infusional 5FU-related cardiotoxicity with initial chemotherapy?
I have a patient who developed documented coronary spasm with EKG changes and troponin elevation on 5 FU infusion, given as part of FOLFOX cycle 1, 3 weeks ago. She is now on the FLOX regimen with Isosorbide mononitrate and amlodipine prescribed by cardiology with specific dosing and timing recommen...
How would you treat a BRAF mutated and KRAS WT metastatic colon cancer who has progressed after FOLFOX and now Irinotecan + cetuximab + vemurafenib?
We have encountered this in our clinic. We opted for clinical trial referral. The BEACON trial showed an impressive ORR of 48% with encoragenib, binimetinib and cetuximab, however, patients with prior exposure to any RAF or MEK inhibitor, cetuximab, panitumumab, or other EGFR inhibitor were excluded...
How do you manage significant fatigue caused by androgen deprivation therapy in prostate cancer patients?
This is a great question and one that I think comes up regularly in the clinic. The fatigue often is due to the hypogonadal state, lack of muscle mass and subsequent loss of muscle power that may reduce stamina. I generally recommend a regular activity or exercise program. As in many other patient p...