Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to systemic treatment of a rapidly progressing, symptomatic, unresectable MPNST arising from a plexiform neurofibroma in a patient with NF1?
The activity of the MEK inhibitor is selective for the benign NF/PN. For the malignant transformation, with aggressive behavior, the SOC chemotherapy regimens are preferred. The SARC trial tested Dox/Ifex and Ifex/VP-16, and these remain the preferred front-line regimens.
How would a low tumor mutational burden (<10) influence your decision to offer neoadjuvant immunotherapy for cutaneous squamous cell carcinoma?
TMB is not an accepted biomarker yet for predicting immunotherapy response in cSCC. If you want to use predictive molecular testing, you can consider using Tempus’s Immune Profile Score (IPS) offered as part of their NGS testing platform. The IPS score is based on a set of genes generated with an AI...
How frequently would you consider IV iron treatment for ongoing iron loss and severe iron deficiency anemia?
Absolutely. You first want to estimate and replace their iron deficit. For patients who are very anemic, they can start at 2-3 grams deficit. I usually don’t give more than 1500 g of iron dextran at one time, but I will have no concern about doing 1000 or 1500 mg weekly until I have replaced their d...
At what time points during a patient's treatment for metastatic ER+ breast cancer are you checking liquid NGS for endocrine pathway alterations?
Traditionally, liquid NGS testing for PIK3CA, PTEN/AKT/PIK3CA, and ESR1 alterations has been performed at discrete clinical decision points, primarily at progression on endocrine therapy or when considering targeted agents.Currently, I order NGS at disease onset, even for those who do not fit INAVO ...
Does being on maintenance pembrolizumab change how you manage patients with partial metabolic response on PET/CT 3 months after chemoradiation for cervical cancer?
No, a good percentage of patients will not have a complete response by 3 months. Six months seems to be a reasonable cutoff. Persistent disease at 3 months does not seem to be a worse prognostic factor than completion at 6 months. At the 3-month mark, I would not manage differently. At 6 months, I w...
How would you approach treatment for a postmenopausal patient who was treated more than 5 years ago with AC-T for TNBC, and who now presents with ipsilateral, locally advanced, node-positive TNBC, but has severe residual neuropathy from prior taxane exposure?
Standard neoadjuvant chemotherapy for TNBC would have been anthracycline- and taxane-based regimens, with the addition of platinum agents (carboplatin or cisplatin) in high-risk cases to improve pathologic complete response (pCR) rates. However, in this case, further taxane use (including docetaxel)...
What is the role of adjuvant radiation therapy for stage III melanoma in the era of adjuvant Opdivo?
I think the role of adjuvant radiotherapy in stage III cutaneous melanoma is difficult to define at this time (June 2019). To be clear, the TROG trial mentioned above showed that adjuvant lymph node basin radiotherapy after therapeutic lymphadenectomy can decrease the chances of lymph node basin dis...
Are certain PD-L1 assays considered more accurate or reliable than others for NSCLC?
In the treatment of NSCLC, squamous or non-squamous, there are three potential checkpoint antibodies available (Nivolumab, Pembrolizumab and Atezolizumab), only one of which is tied to a companion diagnostic of PDL1 expression by IHC (Pembrolizumab) - though in both of the other antibodies, there is...
What is your approach to TNT sequencing for locally advanced rectal primaries with low volume metastatic disease to liver?
This is a very common clinical scenario for which I'm not aware of a single correct answer. I assume by "low volume" metastatic disease to the liver the question implies potentially curable through some combination of liver-directed therapies. The only part of the sequencing about which I am fairly ...
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...