Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients who have exceptionally long responses to HMA with high risk MDS or AML and not candidate for more aggressive therapy/transplant, do you consider treatment holidays or spacing out doses into longer intervals?
Over time, patients with MDS and/or AML on long-term HMA therapy tend to have lower counts, possibly due to less robust stem cell reserve. In general, we prefer to drop the dose (i.e. from 75mg/m2 to 50 mg/m2 for Azacitidine, from 20 mg/m2 to 10-15 mg/m2 for decitabine) as a first. In some patients,...
What is your approach to oligometastatic HER2 positive breast cancer, particularly after excellent clinical response in all sites of disease to trastuzumab, pertuzumab, and a taxane?
The question of optimal treatment of low burden metastatic HER2-positive breast cancer and complete or near complete response to systemic therapy remains open. The two potential strategies are to continue systemic therapy with HER2-blocking antibodies +/- endocrine therapy or to continue the systemi...
In practice, do you discuss the role of Oncotype Dx before ordering the test?
We do discuss the role and implication of Oncotype Dx or any other genomic assay with patients, before ordering it. I make patient aware, how the results will guide us help decide between chemotherapy Vs. No chemotherapy. As a group, we have created an agreed upon criteria for ordering Oncotype Dx, ...
How would you manage a patient with newly diagnosed synchronous triple positive and metaplastic triple negative breast cancers?
Aside from considerations about genetic testing given the dual primaries, and local therapy considerations which I would defer to surgery and rad onc, this case would raise the question of which (neo)adjuvant regimens to consider. I would assess the risk for both cancer independently, and then attem...
Would you resume biologic treatments such as TNF blockers in patients with symptomatic autoimmune conditions who are in remission from their cancers?
Most guidelines in rheumatology recommend use in patients who have been in remission for 5 years or more, there is data for safety for these patients. However, we do not know yet whether TNFi are safe in patients who have been NED for shorter periods and who may be at higher risk of recurrence given...
Should neoadjuvant chemotherapy be recommended for HER2+, clinically LN- breast cancer measuring 2-3cm?
For cT2N0 2-3 cm HER2+ tumors I am still doing neoadjuvant dual blockade chemotherapy for eligible patients in order to assess their pCR status. This guides adjuvant therapy per the KATHERINE study. I usually reserve the APT approach for cT1N0 patients who go to surgery first and are still a stage 1...
How would you approach a patient with Stage III EGFR+ NSCLC who develops oligometastatic disease while on consolidation durvalumab?
This is a difficult situation, I have typically tried local therapies like SBRT initially and then switching to osimertinib with close followup and return precautions
How do you treat patients rendered NED after resection of an isolated lung recurrence of an early stage triple negative breast CA years after adjuvant chemotherapy?
While such patient is at high risk for a subsequent recurrence of metastatic disease, there is no data to suggest that administering 'adjuvant' chemotherapy following resection of a solitary metastasis will improve disease-free or overall survival and thus I would simply continue to observe the pati...
In very rapidly progressive/poorly differentiated hepatocellular cancer, would you use the targeted options (sorafenib/lenvatinib) or would you try a traditional cytotoxic regimen?
The approach to a patient with rapidly progressive hepatocellular cancer is quite challenging. Systemic chemotherapy is of marginal benefit in this disease. Years ago we utilized adriamycin, largely because there were no other agents! We should have learned from studies, albeit early and small ones,...
Would you treat a patient with ESRD on hemodialysis and penile cancer with neoadjuvant ifosfamide?
I do not have a particular expertise in penile cancer. My sense is that neoadjuvant therapy in general is not of proven value in penile cancer and, in someone like this with ESRD, likely to be more toxic than beneficial. The immunotherapy question is interesting, but there are no data to support suc...