Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your experience with directing treatment towards the androgen receptor in metastatic triple negative breast cancer?
There are increasing pre-clinical and clinical data of the potential role for targeting the androgen receptor (AR) in patients with metastatic triple negative breast cancer (TNBC) which express AR. Investigated agents include bicalutamide (Gulap et al CCR 2013) and abiraterone (Bonnefoi et al Ann ...
Outside of a clinical trial, do you currently incorporate the TCGA molecular classification into management decisions for patients with endometrial cancer?
I currently do not use the TCGA or ProMisE classifications to inform adjuvant therapy after surgery. Although exciting, it is premature to use this classification until we have the results of PORTEC-4a. These results will help us to better risk stratify patients and guide adjuvant treatment. That be...
How do you differentiate primary from secondary iron overload?
Medical history helps- transfusion history, chronic hemolytic anemias, ESRD on HD, and inflammatory conditions increase the risk of secondary iron. In my practice, I use MRI to help distinguish between primary and secondary iron overload. In primary iron overload, the iron will only be seen in the l...
Do you recommend ADT or other systemic therapy in patients with rising PSA after prostatectomy and salvage RT and PSMA scan negative for metastatic disease?
Generally, I do not recommend systemic therapy for such patients. If doing so, it would be intermittent ADT (alone) for 6-or 9-month cycles. The EMBARK study will hopefully address this important question.
In which scenarios would you utilize sacituzumab govitecan earlier than third line in the treatment of metastatic TNBC?
To date, we do not have a head-to-head comparison of sacituzumab govitecan prior to the 3rd line setting and insurance approval for sacituzumab govitecan prior to 3rd can be a barrier. However, I consider it under the following circumstances: The patient has significant pre-existing neuropathy. Many...
How do you decide between 1st line PARPi or immunotherapy in a patient with metastatic gBRCA mutated TNBC?
In a patient with a gBRCAm that is PDL1+, I generally consider chemotherapy + checkpoint inhibition in the first line setting given the known survival benefit upfront, and since it is unknown if this benefit with chemotherapy + immunotherapy would be seen in the later line setting. We do have data t...
When do you consider HER2-targeting antibody drug conjugates in the first line setting for metastatic HER2 positive, ER negative breast cancer?
This question cannot be answered for any specific situation with a high degree of reliability without a controlled clinical trial. In my opinion, there could be situations in which I would predict a favorable benefit/risk ratio to the use of T-DXd in first line as opposed to standard taxane + trastu...
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...
How do you utilize CDK 4/6 inhibitors in metastatic ER+ HER2+ breast cancer?
The benefit of adding a CDK4/6 inhibitor to the arsenal of treatment options in the hormone receptor (HR) and HER2-positive metastatic breast cancer setting is unknown. We are trying to answer this question through clinical trials, such as the multi-center Randomized, Open Label, Clinical Study of t...
What second line treatment would you choose for a post menopausal woman with HR+ HER2+ metastatic breast cancer with low burden disease treated with first line aromatase inhibitor and trastuzumab?
The TAnDEM trial did prove that triple-positive metastatic breast cancer should be treated with both anti-HER2 therapy and endocrine therapy. Although there is no direct data in the setting of the above-described case to my knowledge, we can extrapolate from the large body of evidence that exists fo...