Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage immunotherapy-associated pruritis that is persistent despite steroid use?
For pruritus managment, I consider the use of gabapetin, and if refractory to steroids and gabapetin, I consider aprepitant or omalzumab (consider measuring IgE levels), and refer the patient to dermatology for their input.
How do you approach treatment of locoregional squamous cell carcinoma of the stomach extending to GE junction?
Squamous cell carcinomas of the stomach are very rare. There are some published case reports for SCC of the stomach in the metastatic setting. Unfortunately, there are not many series describing the approach for locoregional disease. I have recommended the same approach used for adenocarcinoma which...
Are there any safety or efficacy data regarding the use of EGFR inhibitors in patients on hemodialysis for ESRD?
It's limited. Erlotinib is metabolized in the liver and pharmacokinetic data in patients on hemodialysis is similar to those with normal function. This was reported in a 3 patient case series (Togashi et al, JTO 2010). Appears comparable with osimertinib as well. A case report (Tamura et al, Lung Ca...
Would you add bevacizumab to osimertinib for a patient with NSCLC who is progressing on osimertinib with no other actionable resistance mutations?
This is a good question. This likely stems from the fact there are studies that show the combination of erlotinib with bevacizumab is associated with improved PFS, compared to single agent erlotinib in the first line setting. The combination of osimertinib, a superior EGFR TKI, to bevacizumab is bei...
What adjuvant therapy would you recommend for pT2, pN1 cholangiocarcinoma?
There is no standard of care adjuvant therapy for cholangiocarcinoma. Many of us would feel BILCAP capecitabine did not show enough of the promised improved outcome we all were looking for; and thus many of us would default to gemcitabine plus cisplatin, based on read world data and experience. Many...
How would you approach a patient with advanced stage DLBCL with a single-site of residual FDG-avid disease after completion of R-CHOP in the frontline setting?
First would be to assess the residual activity level (e.g. PS 4 or 5), as sometimes a short-interval PET may show improvement. If concern is for residual disease in setting of PET showing partial response, I would consider biopsy of the residual site prior to making any changes in therapy. Once a d...
How soon after surgery do you start chemotherapy for extensive stage SCLC following resection of a brain metastasis?
I believe chemotherapy is the backbone of therapy for small cell lung cancer. If a patient has asymptomatic brain metastases, I start with chemotherapy (or chemoimmunotherapy) alone and follow with repeat brain imaging. I will treat with RT after initial 4 cycles of chemotherapy if brain disease is ...
For a patient with isolated CNS recurrence of HR+HER2+ breast cancer after completion of adjuvant therapy, what, if any, systemic therapy would you start after completion of local therapy?
It is important to maintain curative intent in this situation. Most typically, patients with ER+/HER2+ (or triple positive breast cancer) are the youngest of all patients with ER+ breast cancer (Alqaisi et al BCRT 2014), and while anti-HER2 therapy is key, it is also critical to emphasize the role o...
How would you approach therapy for a young, fit patient with alveolar rhabdomyosarcoma involving the anterior nasal vault/sinuses in the absence of available clinical trials?
The patient should be risk stratified (as per the Intergroup Rhabdomyosarcoma Study Group classifications) and treated with multimodality therapy, including chemotherapy and likely definitive radiotherapy, depending on the specific location. Surgery is also a consideration, but these are generally c...
Would you assume a diagnosis of metastatic recurrence and initiate therapy for a patient with history of locally advanced NSCLC treated with definitive chemoradiation who develops multiple enlarging lung nodules that are too small to biopsy?
I don't believe that I can point to a study that will answer this question, so will revert to oncologic principles 101, namely that absent exceptional circumstances, we ought to biopsy first recurrence. In the question posed, that is following definitive (curative intent) chemoradiation (and now in ...