Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you decide on the duration of endocrine therapy for premenopausal women who receive chemotherapy and AI/ovarian suppression according to TEXT/SOFT?
Women who have a higher than average risk of recurrence (those who receive chemotherapy, younger than 35 Years, stages II or III ....) derive the most benefit from endocrine therapy +ovarian suppression (using monthly GNRH agonists) for 5 years based on TEXT and SOFT in DFS. The joint analysis of SO...
Should 3 years of adjuvant osimertinib be the standard of care for resected Stage IB-IIIA EGFRm NSCLC?
Since my initial response to this question, the ADAURA study has been fully published (NEJM 383:1711, 2020) and the FDA has approved osimertinib as adjuvant therapy for people with resected NSCLC harboring an EGFR sensitizing mutation. However, neither of these events has altered my opinion that des...
Are there circumstances where you would recommend every 6 week dosing schedule for pembrolizumab monotherapy?
FDA approval for q 6 week dosing of pembrolizumab is awaited but has yet to occur; this would represent a welcome change for our patients, as just happened with the recent approval of q 4 week dosing of atezolizumab. Without FDA approval we are not using pembrolizumab 6 week dosing at this time, and...
How do you choose which LHRH agonist or antagonist to prescribe for ADT in patients with prostate cancer?
The choice of LHRH agonist or antagonist depends on patient factors. Most patients receive some form of leuprolide or goserelin since these allow longer intervals between injections (as compared to degarelix). Goserelin is used more for those on anticoagulation or with bleeding disorders since it is...
When do you suggest ovarian suppression for fertility preservation in premenopausal women receiving neo/adjuvant chemotherapy?
The benefit of ovarian suppression in young breast cancer patients should be looked into from two different aspects. First, the suppression of the ovary resulting in the hormone receptor-dependent cancer stem cell (minimal residual disease) suppression, and second, the preservation of the fertility ...
Do you recommend chemoradiation following neoadjuvant FOLFIRINOX for resectable pancreatic cancer?
Tough question, with lots of evolution in this area in the past few years. The data would suggest that for borderline resectable pancreatic cancer, there is a benefit in terms of OS from preoperative treatment. For unresectable disease, the small chance of conversion into resectability is worth the ...
How would you treat a patient with metastatic NSCLC on pembrolizumab with a sustained complete response, now with 2 isolated small liver lesions?
I am unaware of any "level 1" evidence for this approach, much of our data is anecdotal, however there is certainly reasonable experience of treating "oligo-progressive" disease with local therapies. While there is more experience in adrenal and CNS metastatic disease, I would think that a local the...
Which adjuvant chemotherapy regimen would you recommend for a peri-menopausal woman with synchronous stage IA primary breast tumors, one that is ER+HER2+ and the second ER+HER2-?
I would treat the patient with paclitaxel 80mg/m2 x 12 weeks plus trastuzumab for a year (Tolaney et al., Clin Oncol 2019). The more difficult question is the optimal anti-estrogen therapy: tamoxifen (TAM), TAM + ovarian suppression (OS), or aromatase inhibitor (AI) + OS. This is because the SOFT an...
What is your approach for endocrine therapy in young women (<35 years old) with HR+/HER2+ breast CA with residual disease after TCHP who will start adjuvant T-DM1?
She would be given the options of tamoxifen or ovarian suppression with an AI for five years and then a discussion at that time based on where the data goes in that time. Tamoxifen would have fewer side effects but less effective reduction of PFS per extrapolation from the SOFT/TEXT trials. Ovarian ...
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...