Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What changes, if any, would you make to a patient’s endocrine therapy for a patient with DCIS on tamoxifen for risk reduction who develops a new lesion (LCIS) while on tamoxifen?
Assuming post menopausal I would switch to anastrozole. There are published data on anastrozole for chemoprevention. Although no head to head comparison with tamoxifen A.I.'s superior in every other breast cancer scenario. (second and first line metastatic and adjuvant) Thus nothing to be lost in s...
Would you ever consider offering more than 4 cycles of adjuvant chemotherapy in early stage NSCLC?
As long as a patient received 4 complete cycles of adjuvant chemotherapy, I would not recommend more than 4 cycles to any patient. All randomized trials, which established the role of adjuvant chemotherapy in NSCLC, utilized 4 cycles of chemotherapy. This includes the IALT, NCI-C, and ANITA trials. ...
Do you avoid teriparatide in previously irradiated breast cancer patients with osteoporosis given the black box warning for potential risk of osteosarcoma?
Generally, teriparatide is avoided in breast cancer, previously irradiated or not, because of black box warning. Treatments for osteoporosis (based exceeding fracture thresholds with fracture risk prediction tool e.g. FRAX or Garvin) include oral bisphosphonates, IV zoledronic acid either once or tw...
If a patient on ovarian suppression with goserelin for ER+HER2- BC achieves post-menopausal-range estradiol levels but does not achieve post-menopausal FSH levels, is she suppressed?
Per the package insert and thinking about the mechanism of action with goserelin, FSH levels should be suppressed to follicular phase levels. This usually occurs within four weeks after initial administration of drug and remains in this range. This needs to be kept in mind when following FSH levels ...
How would you approach a locally advanced, radioiodine naive papillary thyroid carcinoma not amenable to a non-morbid surgery?
In certain cases there may a be a potential benefit. We have an 87 year old male with significant co-morbidities that prevented him from being a surgical candidate. Stage 4 papillary thyroid cancer with 1.7 cm right thyroid primary, 2.5 cm RML lung mass and 5 cm right cervical neck mass that was ver...
How do you dose midostaurin in patients with AML who need azole antifungal prophylaxis?
Patients with acute myeloid leukemia are often neutropenic due to the disease or treatment. Anti fungal prophylaxis is often required. The azoles are attractive oral agents. However, they are Cyp3A4 inhibitors. Therefore, for patients taking Midostaurin we use micafungin for anti fungal prophylaxis....
Since the approval of Carbo/VP-16/Atezolizumab (IMpower133) for extensive stage small cell lung cancer, how are you treating those patients who progress > 6 months after chemotherapy alone who were treated prior to the approval of IMpower133?
2nd line anti-PD1 (+/- anti-CTLA4) is reasonable for patients who did not receive atezo in the 1st line setting.
Based on new data from ASCO2019, would you consider gefitinib +chemotherapy instead of osimertinib frontline for EGFRm metastatic NSCLC pts?
While gefitinib + chemo did show a similar PFS as frontline osimertinib, the tolerability and safety profile concerns me. Therefore, I do not plan to change my practice and will still use osimertinib as frontline therapy for my patients with EGFR mutated stage IV lung cancer.
When would you add daratumumab to a PI/IMiD/dex backbone for first-line treatment of transplant-eligible multiple myeloma?
Short answer - in patients with low risk disease.Long answer - CASSIOPEIA enrolled fit patients below 65 years of age with adequate kidney function (greater than or equal to 40 mL/min/1.73 m2) with predominantly stage 1 & 2 disease by the revised international staging system (91% in Dara-VTd, 90% VT...
In light of recent data from ASCO 2019 and the NEJM, would you recommend induction chemotherapy or an adjuvant approach in combination with chemoradiation for locally advanced nasopharyngeal carcinoma?
Definitely, and yes mainly for EBV positive tumors.That trial certainly provides not only rationale for using induction Cis-Gemcitabine, but also the little role left of adjuvant therapy.