Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you offer neoadjuvant therapy to a postmenopausal cT1cN0 , HER2+, ER/PR+ breast IDC or recommend surgery first?
This is currently a very controversial topic, with likely no single straight answer - arguments can be made for both a neoadjuvant approach in light of the KATHERINE trial and for a surgery first approach with treatment de-escalation in light of the APT trial. As others have pointed out, the recentl...
How do you approach adjuvant chemotherapy for high grade large cell neuroendocrine lung cancers?
This is a challenging question given the absence of good data. We know from several studies using NCDB data that adjuvant chemotherapy in resected large cell neuroendocrine carcinoma of the lung is associated with better outcomes, at least for stage IB, possibly not stage I but keep in mind the NCDB...
Would you offer next-line systemic therapy to a patient with LGL leukemia with chronic severe neutropenia, who has had treatment failure with methotrexate, cyclophosphamide, cyclosporine, and danazol?
Response can be slow and delayed. Treatment failure is usually considered after 4 months of therapy. Steroids can be used with methotrexate in severe neutropenia with a slow taper over 4-6 weeks. This strategy seems to potentiate the effect of methotrexate. Evidence after these therapies is limited....
How much emphasis do you place on anti-AR therapy in a patient with metastatic castration resistant prostate adenocarcinoma with progressive neuroendocrine differentiation?
While most prostate cancers are adenocarcinomas, there is a histologic spectrum that includes neuroendocrine and small cell tumors -- with the later typically arising in response to chronic androgen deprivation therapy. Often times we are faced with mixed histologies, which can be challenging to man...
What would be your choice for treatment for an HIV positive patient with no detectable viral load with CD20 negative and CD30 positive DLBCL?
I would really question the diagnosis, especially with the CD30 positivity. Consider peripheral T-cell lymphomas, which are typically CD30+ (ALCL, PTCL-NOS, AICL).
For patients with p16+ SCC of a cervical lymph node subsequently found to have an oropharyngeal mass on imaging, is it necessary to biopsy the primary site prior to proceeding with definitive RT?
No. When it gallops like a horse, there's no need to think of a zebra - unless you're in wild Africa. And if the patient had presented with biopsy-proven p16+ neck node metastatic SqCC with "unknown primary" while a PET/CT showed suspicious uptake at the oropharynx, one should treat the presumed pri...
Do you consider omitting adjuvant radiation therapy in an older patient with node positive TNBC who achieve pCR to neoadjuvant chemotherapy?
It depends on what surgery the patient has received. If lumpectomy plus SLNB, I would not omit unless there is absolute contraindications, intolerance to radiation therapy. PRIME II, CALGB 9343, and this meta-analysis provided evidence that post lumpectomy radiation therapy can be omitted in women >...
Would you offer maintenance lenalidomide or rituximab in a patient with DLBCL transformed from a marginal zone lymphoma in a young, fit patient?
No. There is no role for maintenance therapy in aggressive lymphomas (transformed or not). This is based on the assumption that DLBCL is curable and randomized trials evaluating maintenance therapy in de novo disease did not show an improvement in survival (see HOVON Nordic trial). Dedicated trials ...
In patients with metastatic lung SCC who are on pembrolizumab maintenance after starting pembrolizumab/carboplatin/nab-paclitaxel, what is your treatment strategy if they progress while on pembrolizumab alone?
Several great questions here, largely unanswered. What is the role of platinum rechallenge in stage IV NSCLC? I generally do not revisit platinum (recall the higher risk of a carboplatin infusion reaction with multiple courses), but if the initial response was remarkable, it would be worth consideri...
How do you diagnose MDS in a patient with equivocal morphological findings?
Cytopenic patients suspected of having MDS may often have equivocal findings in the bone marrow such as insufficient dysplasia and a blast proportion of less than 5%. This does not necessarily preclude a diagnosis if other features are present. For example, persistent, otherwise unexplained monocyto...