Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with metastatic NSCLC, PD-L1>50%, after progression on first line checkpoint inhibitor, do you prefer chemotherapy alone or chemotherapy added to the immunotherapy?
In general, I would say that chemotherapy alone would be the recommendation with the caveat that if disease progression can be treated ablative, then I continue pembrolizumab (I've had only 1 or 2 patients who fall into this category). I base this impact on a number of case reports as well as a smal...
Would you consider "adjuvant" pembrolizumab for a patient with muscle invasive bladder cancer who is cisplatin ineligible and found at surgery to have T4aN2M0 disease?
This good question will be answered in the ongoing AMBASSADOR trial led by @Dr. First Last at NCI (pembro vs observation phase 3 adjuvant trial). There is also another adjuvant IO trial: Checkmate-274 trial (nivolumab vs placebo), while IMvigor010 did not meet primary endpoint of DFS benefit with ad...
How do you approach HER2 directed therapy with discrepant results between FISH and Oncotype?
At our institution, we don’t do Oncotype for HER2+ (by IHC or FISH) cases. See our published data showing the discrepancy.
How would you manage adjuvant treatment of a patient with ER+/PR+/HER2+ breast cancer and a small amount of residual disease (e.g. T1mi) following neoadjuvant TCHP?
The benefit for TDM1 was seen in the subset analysis of KATHERINE patients with residual tumors under 1cm (including T1mic) HR .66 and about a 5% absolute risk reduction. So I agree with @Dr. First Last that switching to TDM1 should be discussed with the patient.
Is there still any role for afatinib (or first generation TKIs) in the management of EGFR mutated metastatic lung adenocarcinoma?
Yes, there is still a role for Afatinib for certain uncommon mutations, especially exon 18 deletions, E709X, G719A, and S768I, where the IC50's are sometimes 10X better for Afatinib than osimertinib. I have seen clinical responses to Afatinib in tumors with these mutations progressing on osimertinib...
When would you use oral cedazuridine/decitabine as opposed to parenteral HMAs to treat intermediate or high risk MDS?
Oral cedazuridine/decitabine was approved in the US for the treatment of intermediate and high risk MDS and CMML based on its equivalent exposure to 20 mg/m2 of IV decitabine in Phase 3 study. Drug related toxicities and response rates were as would be historically expected for IV decitabine (full d...
How do you adjust the dose of Ibrutinib in hepatic dysfunction, particularly if disease related?
It's an interesting question, but I have never seen such a case. Ibrutinib rapidly clears tissue disease, and hence, the liver dysfunction, if truly CLL-related, should improve on therapy. Given the unusual scenario, I would consider starting at a low dose, 140 MG daily, and titrate up to 280 MG aft...
How would you treat a patient with metastatic NSCLC with repeated episodes of CNS brain metastases but otherwise with good systemic disease control on maintenance therapy?
The answer to this question would have been easy 10-20 years ago - you would give whole brain radiation. With the routine incorporation of SRS for brain mets and better systemic therapies, the trend over the last few years has been to go away from whole-brain radiation. Whole-brain radiation has bee...
For locally advanced rectal cancer, would you consider utilizing the RAPIDO trial approach of short course radiation followed by neoadjuvant chemotherapy prior to surgery?
RAPIDO trial is an important study since it is the first phase III study that reported final results of a total neoadjuvant treatment (TNT) approach for rectal cancer.The RAPIDO study is a European study and we need to be aware of the practice difference (in the US, we traditionally use neoadjuvant ...