Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage a recurrence of colon cancer within 3-4 months of completion of adjuvant FOLFOX?
I think the critical point here is NGS panel done quickly and used to judge your next step. For example, your approach would be different for KRAS mutated cancers vs BRAF V600E mutated cancers, etc. Generally, you would choose a non-FOLFOX regimen for relapse this soon after completion. This is a ve...
In which patients do you offer adjuvant bisphosphates in breast cancer treatment?
I would offer adjuvant bisphosphonate in postmenopausal women with moderate to high risk early stage breast cancer and in patients with osteopenia or osteoporosis needing aromatase inhibitor therapy. I would share the data regarding efficacy and side effects with the patients for shared decision-mak...
Do you consider prior use of cisplatin for a previously diagnosed cancer a contraindication for its use as radiosensitizer in a new head & neck cancer?
No. Platinum remains the standard of care as a radiation (RT) sensitizer for locally advanced head and neck cancers whether treatment first-line or in the recurrent setting. To date, there is no data to support an alternative radiation sensitizer even if disease recurs and re-irradiation is consider...
What is your preferred adjuvant chemotherapy regimen for a patient with local recurrence of TNBC two years after completing neoadjuvant ddAC-T who declined prior adjuvant capecitabine?
There is no clear data-driven option for a patient with TNBC local recurrence, although the underpowered CALOR study does support the use of chemotherapy in the local recurrence setting. I would offer this patient a taxane + carbo + pembro for 4-6 cycles if she doesn't have significant neuropathy. T...
How would you treat Stage III unresectable adenocarcinoma of the lung with a BRAF-V600E mutation?
At this time, I do not think there is any role for BRAF directed therapy in patients with stage III unresectable adenocarcinoma. The standard of care remains chemoradiation followed by durvalumab. There is no evidence to support doing anything else. Unlike EGFR, for instance, where the use of consol...
Would you consider maintenance immunotherapy after cisplatin-gemcitabine chemotherapy and chemoRT for stage 3 bladder cancer in a patient declining cystectomy or who is a poor surgical candidate?
Great question and relevant clinical scenario. We need a clinical trial in this setting, the INSPIRE (EA8185, PI: Dr. @Dr. First Last) is an ideal trial to enroll. In the meantime, would not add "consolidation/maintenance" ICI in the absence of data in this particular setting.
How do you approach patients with malignant melanoma who are disease free on immunotherapy for over 3 years?
The prognosis of metastatic melanoma patients treated with immunotherapy has improved considerably. Based on the 6.5-yr update to the CHECKMATE-067 study (presented at ASCO 2021 meeting), the OS for patients treated with ipi/nivo is 49%, 42% for nivo alone, and 23% for ipi alone. If the patient has ...
In G1 metastatic GEP-NET with small lesions visible on PET dotatate, very low burden of disease on CT and no clinical symptoms, are there any data to suggest early lanreotide changes natural history of disease and prolongs OS vs observation until symptoms?
The answer is no, there is no such data supporting an early intervention. The keywords here are "no clinical symptoms". For patients with functional panc NETs or siNETs with carcinoid syndrome, initiation of somatostatin analog (SSA) therapy is indicated for syndrome control.The NCCN, ENETS, and NAN...
Is there a role for systemic therapy in recurrent oligometastatic triple negative breast cancer with brain only disease?
There are certainly no randomized trials in this setting. I will try to provide some thoughts and rationale for discussion, but encourage shared decision-making with the patient and multidisciplinary team. I am also curious about others' thoughts in this arena.CNS-only relapse is unusual but there a...
How would you treat a patient with metastatic RCC with high grade neuroendocrine and sarcomatoid features after progression on IO + TKI?
This is quite limited information. What is the underlying diagnosis, unclassified or something else like clear cell? Remember that sarcomatoid (and rhabdoid for that matter) are states of differentiation and not a true histologic diagnosis. We often think of the presence of neuroendocrine features a...