Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
How would you approach patients receiving neoadjuvant pembrolizumab (SWOG 1801) for melanoma with no response to systemic treatment?
There isn't a definitive answer to this question as patients without a pathologic response tend to have the worst outcomes in terms of relapse-free survival outcomes. There is no prospective data to support the change in treatment strategy from single agent to dual agent, especially in the absence o...
How would you sequence treatment of a synchronous IC1 high-grade serous ovarian cancer and cT3N1 rectal cancer?
In a patient with history of successfully treated locally advanced H&N cancer, how do you discern between a metachronous second primary locally advanced lung SCC vs. metastatic head and neck SCC?
Solitary, particularly long interval, N0-N1, treat like lung primary. Multiple lesions, short interval, advanced neck disease, likely metastases.
Would you offer adjuvant chemotherapy after SBRT for biopsy proven sub centimeter metastatic pulmonary nodule from rectal cancer?
This is a great question and a common scenario we met in the clinic. First, we need to know more about the case, for example, if the patient has synchronous metastatic disease or it is metachronous metastatic lesion; if the patient had neoadjuvant/adjuvant chemotherapy; how long of the disease-free ...
Would you offer a different ALK inhibitor to a patient receiving alectinib who had decompensation of liver function in the setting of preexisting cirrhosis?
Short answer is yes. In the pivotal phase III studies that compared alectinib, brigatinib, and lorlatinib to crizotinib in the first line setting (Peters et al., PMID 28586279, Camidge et al., PMID 30280657, Shaw et al., PMID 33207094 respectively), the risk of hepatic dysfunction (defined by increa...