Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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 ...
Are you recommending aspirin in breast cancer survivors?
I do not recommend aspirin in breast cancer survivors routinely. The role of aspirin in terms of improving survival is not clear yet- with some observational studies showing a benefit but no prospective high level evidence. There are a couple of large studies looking at this. There are various intri...
Would you consider nivolumab and ipilimumab as first line for pleural mesothelioma?
I found the overall survival benefit of Checkmate 743 presented at the WLCL presentation compelling. This is the most significant phase III data we have had and I was particularly encouraged by the sarcomatoid subset - traditionally much harder to treat - seeming to benefit at least the same if not ...
How do you approach the treatment of patients with an e14a3 (b3a3) BCR-ABL fusion in chronic phase CML?
The treatment is the same; the problem is how to monitor response as this rearrangement is detectable reliably by FISH and not by the typical RT-PCR. There is a report showing that CML with some rare fusion genes have a rapid response at early time points (3 and 6 months), but long term outcome seem...
How would you manage a patient who develops pleural and skin metastases shortly after completing neoadjuvant ddAC-T and surgery for a locally advanced triple negative breast cancer?
Any solid tumor refractory to frontline chemotherapy has three pathways moving forward:1. Clinical trial2. NGS on tissue to identify FDA approved targets (specifically BRCA in this case)3. Standard second line therapies.Under option 3: For PD-L1 > or = 1%, the combination of atezolizumab and nab-pac...
Can fulvestrant cause a tumor flare reaction in hormone receptor positive breast cancer?
No. Fulvestrant does not have agonist activity on the estrogen receptor, so it will not cause a true tumor flare. When it is paired with an LHRH agonist for a premenopausal woman, the LHRH agonist can cause an initial tumor flare because of the rise in estradiol before full ovarian suppression kicks...
How would you approach systemic therapy for a postmenopausal female with metastatic ER+/HER2+ breast cancer (liver/bone) who achieved a CR for 5 years on trastuzumab/pertuzumab and exemestane, with continued asymptomatic brain progression?
Switch to tucatanib, capecitabine, and trastuzumab. Consider returning to trastuzumab/pertuzumab based treatment at future systemic progression since currently there's no systemic progression. Consider continuing exemestane. This could be based on recent NSABP trials showing no detriment to concomit...
For pregnant patients progressing on anthracycline based chemotherapy (ex: FAC), would you consider other chemotherapeutics such as taxanes or proceed to locoregional treatment?
Typically we would treat with anthracycline based therapy, followed by surgery and post delivery taxanes. In this case, she would need to proceed with surgery sooner than later and receive post-delivery taxane based therapy.
How do you treat primary retroperitoneal choriocarcinoma with liver and lung metastases and markedly elevated B-HCG?
A primary retroperitoneal choriocarcinoma may or may not actually be an occult testis primary, despite the testis being a relative sanctuary site, with normal exam and ultrasound, and no indication for orchiectomy. He has poor risk of disease and needs 4 courses of triple drug therapy, usually with ...
How would you manage a young patient with newly recurrent metastatic triple negative breast cancer less than a year after completing adjuvant chemotherapy and worsening liver function due to intrahepatic disease?
Since she has a DFI less than 1 year from last taxane exposure, I would consider her taxane resistant. In general, I try to do carboplatin/gemcitabine, especially if the LFTs are abnormal. If her PDL1 is positive, you can try to add pembrolizumab similar to the KEYNOTE355 regimen. Following this oth...