Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with metastatic SCC of the larynx, PD-L1 <1, unable to tolerate 5-FU based chemotherapy due to grade 4 esophagitis/mucositis?
For patients with PD-L1 zero metastatic head and neck squamous cell cancers, standard of care is platinum/5-FU/Pembrolizumab for first-line management. The mucositis from 5-FU can be very difficult for patients to tolerate, so if dose reductions do not meaningfully allow for tolerability, I switch t...
Is there a role for adjuvant pembrolizumab/capecitabine in a patient with TNBC who receives neoadjuvant AC-T with residual disease found at time of surgery?
Based on CREATE-X, there would be data to support using adjuvant capecitabine in this scenario. As for pembrolizumab, there is emerging data that the benefit of the checkpoint inhibitor may be limited to the neoadjuvant setting based on the recent negative IMpassion030 trial of adjuvant atezolizumab...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
How do you approach a breast cancer patient with outside pathology returning as HER2 positive on FISH but internal pathology review showing conflicting results and HER2 negative on FISH on same sample?
I will give some thoughts but appreciate other opinions as well. First, it is important to consider the labs performing the assessment and their level of comfort/expertise in this assay (i.e. which do you trust).Next, it's important to recognize that especially in borderline cases of Her2 positivity...
What is your preferred first line therapy in well differentiated GI NET with Ki67 > 55%?
Without much detail provided here, I think understanding the biological behavior of this tumor is a key detail. For more indolent biology, you can use everolimus or SSA therapy, for example. For more aggressive disease, you would lean toward cape/tem, etoposide/platinum, or FOLFOX. An excellent trea...
How would you approach patient with known Lynch Syndrome who developed a gall bladder cancer which on pathologic testing of the tumor by PCR and immunohistochemistry is pMMR and MSS?
Assuming advanced/metastatic disease, for MSS disease, I would use frontline chemoimmuno therapy with cis+gem+durva/pembro. In this case, response to immunotherapy alone may not be comparable to MSI-high disease thus, hesitant to use pembro alone.
Which adjuvant chemotherapy would you offer to a MSI high pancreatic cancer patient after Whipple?
Not yet ready for IO alone. Can add IO to FFX maybe.
After seeing results from GOG238, is there a subset of patients that might still benefit from chemoradiation for centrally recurrent endometrial cancer?
It’s hard to know who would benefit but use for bulky or high grade central recurrence. Bulky is subjective but usually for lesions that are more likely to need interstitial brachytherapy.
How would you manage a patient with NLPHL and CKD who relapsed after a long disease free interval (i.e. 7 years) following bendamustine?
I honestly might consider BR again depending on the counts. I personally use as little as possible - often stopping the B after 3-4 cycles if the patient is in remission.
Do you treat patients with resected adenocarcinoma of the intrapancreatic bile duct along a biliary paradigm or pancreatic paradigm?
I doubt this distinction can be made with any accuracy. In this anatomic site, the differences between pancreatic, biliary, and ampullary carcinoma are extremely difficult to differentiate based on any objective criteria. Therefore, the best approach is to make a diagnostic estimation and consider t...