Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a solitary liver met of pancreatobiliary origin with neoadjuvant chemotherapy required for preoperative downstaging, would you recommend mFOLFIRINOX or Gem-Cis?
It depends on the patient’s performance status. If the patient can handle the three drug regimen, then I would attempt it. I would offer a very quick surveillance scan after 4 to 6 weeks to see if there’s a response. If not, would consider switching. NGS panel may also be considered.
How would you approach a patient with metastatic ER+/Her2+ who has progressed on trastuzumab/pertuzumab + tamoxifen after being in remission for 4yrs?
There are several options for this patient, including 1) continuing Herceptin/Pertuzumab and change tamoxifen to a different hormonal therapy agent, 2) continuing Herceptin/Pertuzumab and switching hormonal therapy to a taxane, 3) switching to T DM1, 4) clinical trials of targeted agents such as CDK...
How would you treat a patient with poorly differentiated carcinoma with squamous differentiation of the kidney following nephrectomy with metastatic retroperitoneal adenopathy?
Depending on the patient’s age and performance status I would determine if retroperitoneal dissection is an option (assuming that’s the only site of metastatic disease) If possible, send the pathology specimens out for a second or third opinion. I would also consider next-generation sequencing, as ...
At what doses of steroids would you feel it's acceptable to either initiate or resume checkpoint inhibitors?
In clinical trials, most trials did not allow patients to receive therapy if they were receiving 10 mg or more of prednisone (or equivalent). In clinical practice, patients on a higher dose of steroids are often interested in receiving therapy. Although some data indicate worse outcomes among patien...
Would you consider offering neoadjuvant concurrent chemoradiation to a young (<50) patient with adenocarcinoma of the GE junction with a site of solitary metastasis (bone)?
In general, my approach to the patient with a solitary site of metastasis from GE junction cancer is to start with chemotherapy. If their disease is responsive over a few scans, it’s reasonable to then “consolidate” with chemoradiotherapy to the primary tumor site. If progressive metastatic disease,...
How would you manage a local recurrence at the skull base after concurrent chemoRT for locally advanced nasopharyngeal carcinoma?
Available data does not support re-irradiation when the recurrence is less than 1 year after primary treatment. In this case I would favor systemic therapy, either with platinum-gemcitabine or Pembrolizumab if pts tumor is PD-L1 positive.
In a patient with intermediate risk castration sensitive prostate cancer S/P prostectomy and now with biochemical recurrence + regional lymph node involvement 8 months post RP, would you do hormonal therapy (ADT or ADT+Abiraterone) with or without EBRT?
Yes, node positive (N1 M0) patients such as this were eligible for the STAMPEDE trial of ADT +\- abiraterone even in the relapsed setting after local therapy. These patients have both a disease free and overall survival advantage with abiraterone. See NCCN guidelines 2019.
How would you approach a patient with metastatic HER2+ breast cancer on TDM-1 with progression in the breast and stable systemic disease?
Progression is progression whether it is in breast or distant sites. The question in my mind is that was there inadequate primary surgery of this breast or possibly a different clone of cells. Practically speaking this is often hard to distinguish. It would helpful to know if this a metastases that ...
Do you check baseline or surveillance audiometry (if not overtly symptomatic) to screen for hearing loss in all patients getting cisplatin?
I disagree. When we started testis studies in 1974 with PVB, we did baseline audiometry and repeated it at 9 weeks, 3 months and 6 months. Everyone experiences a certain degree of high frequency hearing loss which is usually reversible. During the past 40 years we NEVER get baseline audiometry as te...
How would you approach a patient with localized breast cancer who had a low Oncotype Dx recurrence score but a 20% risk of distant recurrence (without chemotherapy)?
The question asks how to treat a patient with a low Oncotype Dx score, but an estimated risk of recurrence of 20% without chemotherapy. I am presuming the estimated recurrence risk is based on clinical parameters, such as tumor size and grade, independently from the molecular profiling data. If this...