Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When do you consider upfront surgery for locally advanced (T4) sinonasal CA?
I usually favor upfront induction chemotherapy for the unresectable cases or if upfront surgery has the risk of unacceptable morbidity. We then evaluate the role of surgery based on histology. For most histologic sub-types of sino-nasal malignancy, we favor primary surgical resection (salivary gland...
What would be your next treatment in a postmenopausal woman with metastatic ER+ lobular cancer with progression on palbociclib/letrozole with multiple liver metastasis?
I will assume this patient achieved median PFS and DOR as seen in first line studies with AI/CDKi prior to her progression. Some options for next line treatment include:1) Fulvestrant single agent2) Fulvestrant + everolimus / Exemestane + Everolimus3) Fulvestrant + alternate CDKi (preferably on tria...
How do you choose between adjuvant PCV vs temozolomide in high risk oligodendroglioma with IDH mutation and 1p/19q co deletion?
In our practice, we typically offer procarbazine/lomustine (with or without vincristine) to all patients with high risk oligodendroglioma, IDH mutated, 1p/19q codeleted. Temozolomide based on the Stupp regimen is used as an alternative when there are specific concerns for PCV related toxicity or str...
Would you recommend EBRT/brachythrapy for any patients with stage III- IV uterine ca in light of GOG-258 data?
GOG-258 will certainly change management approach. The recurrence pattern between the two arms (higher distant mets in chemo RT arm and higher locoregional recurrence in chemo alone arm) suggests that sequencing of treatment may also matter. Our current approach is to have chemotherapy first and con...
Which patients with metastatic hormone sensitive prostate cancer would you treat with enzalutamide or apalutamide (instead of abiraterone or docetaxel)?
Current studies in mHSPC combining docetaxel or abiraterone or enzalutamide or apalutamide suggest that the standard of care for patients who present with de novo high volume metastatic disease has now changed from single ADT (gonadal androgen suppression) to one of the combinations. At this point i...
Which patients age < 50 with OncoType score < 11 do you offer ovarian suppression?
For T1-2N0 very low risk disease the TAILORx data demonstrated a less than 5% risk of distant recurrence regardless of clinical risk. (Sparano et al NEJM 2019) The majority of premenopausal were given tamoxifen alone. The absolute difference between tamoxifen and OFS/AI in such a low risk group woul...
Is immunotherapy the next best option for a patient with metastatic translocation-associated renal cell carcinoma (TFEB rearrangement) after progression on 1st line sunitinib and 2nd line everolimus/lenvatinib?
I would be very skeptical of immunotherapy success in this situation. If I understand this tumor is driven by a specific fusion and the subsequent production of presumably the downstream proteins is driving this tumor. Its occurrence in younger age is typical of translocation driven tumors, and it o...
How do you manage local/mesenteric lymph node recurrence of colon cancer after surgery and adjuvant therapy?
Management of oligometastic colorectal cancer is a frequently encountered clinical problem. The success of local therapy for liver metastases has been well studied, with survival rates as high as 25% at 10 years for this population (Kanas GP, et al, 2012). The value of this approach has been extrapo...
For a woman with baseline neuropathy, is there any evidence to use a different chemotherapy with atezolizumab in metastatic triple negative breast cancer?
Unfortunately, there is no published clinical trial evidence for using atezolizumab with chemotherapies other than nab-paclitaxel. There are ongoing trials, such as IMpassion132, but they have not reported results. Trials presented at ASCO 2019 include COLET (atezolizumab plus cobimetinib with eithe...
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...