Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What duration of ADT do you recommend for patients with high risk or very high risk prostate cancer who undergo radical prostatectomy, adjuvant RT, and adjuvant docetaxel?
Locally advanced prostate cancer remains a significant clinical challenge. The role of "adjuvant" docetaxel to follow patients receiving primary radiotherapy plus ADT has been tested in at least 5 randomized studies, with RTOG 0521 the only one to my knowledge showing survival benefit (albeit a smal...
What would be your next line of therapy for a postmenopausal metastatic ER+/Her 2- BC, s/p anastrazole and palbociclib/fulvestrant who has progressive disease and ESR1 mutation on ctDNA?
Patients with metastatic, hormone receptor positive, HER2 negative breast cancer who develop disease progression after aromatase inhibitor followed by fulvestrant and CDK4/6 inhibitor and have tumors with ESR1 mutation represent a therapeutic challenge. In patients whose cancer cells harbor PIK3CA m...
Given the results of KEYNOTE-062 presented at ASCO 2019, how will you utilize immunotherapy in gastric cancer?
Interpretation of Keynote-062 study results is complicated. The primary endpoint was non-inferiority of pembrolizumab alone versus chemotherapy for first line therapy in patients with CPS>1. This primary endpoint was met, however the PFS curves are quite revealing in that chemotherapy arm does much ...
In refractory germ cell tumor, in the absence of results of the randomized TIGER trial, how do you determine if patients should be treated with conventional-dose chemotherapy versus high-dose chemotherapy?
Many germ cell tumor experts including myself believe that the important questions asked by TIGER trial are already sufficiently answered and the impact of the trial is likely to at the very least be low. A number of germ cell tumor expert centers have chosen not to participate in the TIGER trial be...
Would you give additional chemotherapy with taxane for a patient with triple negative breast cancer who has achieved pathologic complete response with Adriamycin and cyclophosphamide?
If there are no medical reasons to hold it and we believe the patient will tolerate it fairly well, I would give it. A large metanalysis presented at SABCS showed no difference in outcome between patients who received extra chemo or did not, after pCR. While these data give me comfort in omitting e...
How would you interpret a negative ER by PCR via Oncotype, but positive (60%) based on IHC staining?
I would want pathology to be reviewed again to see if there are ER+ and ER- areas, to explain the discordance in ER expression via Oncotype Dx and IHC. It is possible that the Oncotype Dx was run on the ER- portion.
Would you finish neoadjuvant TC in a postmenopausal stage I TNBC patient who transferred care to your practice after 1 cycle or would you proceed with surgery and finish chemo adjuvantly?
Since I often administer TC x 4 in the adjuvant setting to patients with stage I TNBC, I would definitely be comfortable continuing this regimen in the neoadjuvant setting in such a patient. I use TC in these patients based on results from the ABC analysis (Blum et al, JCO 2017) which demonstrated a...
What is your approach for locoregional mediastinal recurrence of NSCLC adenocarcinoma in fit patients >5 years from definitive treatment (chemoradiation and/or surgery)?
There are a lot of variables here including number of lymph node stations involved, bulky vs non bulky disease, and lung/cardiac function. I would treat this similar to de novo diagnosis given the timeframe from prior treatment as this is unlikely to be an isolated relapse this far out. Definitive c...
After partial mastectomy, would you consider Oncotype for an older male with HR +/Her 2- IDC, T1cN0, Grade 2 disease?
That depends on her estimated life expectancy based on her comorbidities, performance status and geriatric assessment. I also would take into account whether the patient is able to tolerate chemotherapy, particularly what is the risk of deconditioning and loosing independence due to long term toxici...
How do you treat a patient who develops metastatic prostate CA while on enzalutamide or apalutamide for originally M0 CRPC?
Most patients in this setting actually have mCRPC but very low volume disease. Occasionally this can be local/regional only but most PET imaging studies suggest that M0 CRPC is comprised of metastatic disease below the limits of detection of conventional CT and bone scan imaging. Thus I manage these...