Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In what circumstances, if any, do you administer concurrent capecitabine with radiation therapy in the treatment of breast cancer?
We rarely, yet selectively use concurrent capecitabine radiation therapy (CCRT) for management of breast cancer. A couple of instances we would consider using concurrent capecitabine at radio-sensitizing dose is when we have to treat bulky local-regional disease with radiation. We make a consensus d...
Would you use neratinib in a very-high risk Her-2 positive breast cancer patient who is ER-?
ExteNET trial of neratinib, given for one year after completion of adjuvant trastuzumab, showed a small improvement in DFS. No OS benefit. HR-positive patients derived most of this small DFS benefit. I don’t think HR-negative patients will benefit at all. But for patients who are at incredibly high ...
Would you treat a young patient with de novo triple negative breast cancer metastasis to the superior mediastinum as locally advanced with chemotherapy followed by radiation or palliative chemo immunotherapy if PD-L1 positive?
While this patient clearly meets criteria for M1 disease, if the superior mediastinum is her only site of disease beyond the breast and regional nodes I would give her 'the benefit of the doubt' and at least start her treatment with curative intent, since we can eradicate bulky disease in the breast...
Do you offer bevacizumab to patients more than 65 years old with metastatic colon cancer that are KRAS mutant?
Great question. I think the data would argue that on a case-by-case basis you can give bevacizumab safely. Metaanalyses suggest that PFS and OS are improved in a statistically significant way with the addition of bev (PFS HR 0.55, OS HR 0.83), but so are AE's (Fistula OR 12.07!!, Arterial embolism O...
How would you approach a patient with Gleason 9 prostate cancer and regional lymphadenopathy as well as inguinal lymphadenopathy (M1a) but no bone metastases?
Definitely warrants a balanced discussion. Systemic therapy as the mainstay is definitely the right answer--long-term ADT for sure, at minimum. I think offering to treat the prostate with RT is fair, based on STAMPEDE. For a fit patient with good life expectancy, I would explain to the patient that ...
How much later after starting a hypomethylating agent in an elderly patient with AML being treated in the upfront setting can venetoclax be started?
It can safely be started at that time, but the outcomes may not be quite as optimal as when used from cycle 1. There is not much data about this, but when used after patients have had progression with prior exposure to hypomethylating agents, responses are sometimes not as robust (see ASH abstracts ...
Would mild hemophilia A that does not require frequent factor replacement be an absolute contraindication to anti-VEGF medications when indicated?
There is one report in the literature of the use of bevacizumab and chemotherapy in a patient with mild Hemophilia B and metastatic colon cancer. The patient tolerated the combination without bleeding and his hematologic monitoring remained unchanged on the combination. The package insert does descr...
How would you approach therapy for a patient with newly diagnosed non-GC DLBCL with previous anthracycline exposure?
For fit patients with prior anthracycline exposure for non-lymphoma healthcare who are fit for chemotherapy and with preserved LV function, I would recommend considering daR-EPOCH. The history of the regimen was its original development as treatment of relapsed lymphoma after 1L bolus doxorubicin, a...
How do you approach gastric cancer with oligometastatic disease?
This is an area of ongoing evaluation and controversy. As with any such areas, there is a lot of dogma and no good data (other than single-center retrospective series from East Asia and, occasionally, the West). The FLOT5 study will indeed hopefully answer this question definitively.FLOT5 is based o...
How would you manage a patient with ER+ HER-2+ metastatic disease on T-DM1 with NED for over 2 years, now with an isolated recurrence that is ER+ but HER-2 negative?
Odd presentation. Would talk to the pathologist about the receptors status and consider repeating those. If this is truly ER+ and HER2 negative, I would keep the T-DM1 going and add an AI