Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach use of tamoxifen for chemo-prevention in post-menopausal women with non-BRCA germline mutations?
I am not aware of any prospective studies specifically looking at non-BRCA mutations and tamoxifen’s role in chemoprevention in this population, although some retrospective studies in BRCA mutated patients have demonstrated a significant beneficial effect.The NSABP breast cancer prevention trial dem...
What is your initial treatment strategy for patients with TNBC who present with isolated bulky axillary and cervical adenopathy?
I assume that the question applies to a patient with bulky axillary and ipsilateral cervical adenopathy, with or without a demonstrable mass in the ipsilateral breast, and without overt metastatic disease elsewhere in the body. While the presence of cervical (not supraclavicular) nodes is considered...
How would you manage a patient with high risk triple negative breast cancer with metastatic disease after recent adjuvant AC-T?
If she relapsed within 12 months of her adjuvant paclitaxel, then I would consider her TNBC taxane resistant. These patients weren't enrolled in Impassion130 and many first line trials exclude patients with short DFI. If a trial is available, consider it whenever possible. I would do BRCA germline t...
Do you ever stop pertuzumab for stable disease in a patient with metastatic, HER2 positive breast with stable disease?
I would only stop pertuzumab if there is considerable toxicity (rashes, diarrhea, severe infusion reactions, etc). Given the substantial overall survival benefit seen in the CLEOPATRA study, I make every effort to continue both trastuzumab and pertuzumab in patients with metastatic HER2+ breast canc...
Are there any data to guide choice of immunotherapy agent in first line treatment for extensive stage small cell lung cancer?
Both the addition of durvalumab and atezolizumab to platinum etoposide resulted in a modest improvement in median progression free, overall survival and saw twelve-month overall survival rates just above 50%. The ECOG-ACRIN phase II trial of nivolumab added to platinum etoposide also improved PFS an...
How would you approach a postmenopausal patient with HR-,HER2+ breast cancer who has oligometastatic disease, and is s/p complete resection of brain met with no other evidence of systemic disease?
For local control, I would do stereotactic radiosurgery to the resection cavity. This is in line with NCCN guidelines and randomized trials, such as N107C, that show excellent local control with similar survival and better QOL compared to whole brain radiation.I would also recheck markers on the bra...
Would you consider neoadjuvant ifosfamide-based chemotherapy for a large (>10cm) high grade soft tissue extremity sarcoma in an attempt to achieve limb sparing surgery in an otherwise healthy young patient?
This question is similar to one previously posted:Are there any types of sarcomas that you use induction and/or concurrent chemotherapy with radiation prior to surgery?In cancers where chemotherapy confers a survival benefit (e.g. breast, osteosarcoma), chemo before or after surgery is fine. I would...
How do you manage oxaliplatin-induced acute peripheral nerve hyperexcitability?
This can be very frustrating for both the patient and the treating physician, as there is little that we can do to prevent this from happening. I have found that assurance is the most important thing that we can do for patients. For example, some patients can develop pharyngolaryngeal dysesthesias (...
How do you manage patients with pancreatic adenocarcinoma who progress during neoadjuvant FOLFIRINOX, such that borderline resectable disease is now unresectable but still localized?
Great question; this area is rapidly evolving. I hope some of the ViewRay crowd will see this and chime in. We give ablative doses of radiation (~100Gy BED). That results in survival that is similar to surgery in patients like this (inoperable in an aggressive surgery practice at MSKCC, MSS in prepa...
Would you consider adding Enasidinib to frontline combination therapy with HMA and Venetoclax in a patient with newly diagnosed AML with IDH2 mutation that is >75 or unfit for standard induction therapy?
This question raises an important treatment consideration, but I would probably not use triple agents at this stage given lack of maturity of clinical trials. Venetoclax has been quite effective in those who have IDH1 and IDH2 mutations (Chan SM et al Nat Med 2015; 21:178), so I would probably start...