Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage a HR-/HER2+ breast cancer patient with local progression during neoadjuvant TCHP?
With the robust activity of HER2-targeted agents in the operable setting, this is a highly concerning clinical scenario. I would retest for HER2 on the biopsy specimen and confirm its positivity. Also, I have significantly limited the use of anthracyclines in patients with HER2+ breast cancer - give...
For patients with RET-fusion+ NSCLC who progress on RET inhibitors, do you repeat tumor molecular profiling before selecting subsequent therapy?
Yes, I repeat molecular profiling, ideally with both repeat tissue and liquid biopsy.
Do you offer adjuvant androgen deprivation therapy for AR+ salivary ductal carcinomas treated with curative intent?
There is a recently released ASCO guideline [Geiger et al., PMID 33900808] which specifically addresses the role of systemic therapy in the management of salivary gland malignancies.Regarding systemic therapy, the recent ASCO guideline suggests concurrent chemotherapy, HER2-Neu targeted therapies, a...
What is your preferred 3rd line therapy for patients with metastatic sarcomatoid RCC?
There is no standard 3rd line therapy for sarcomatoid RCC. We know from gene expression data and clinical trials that sarcomatoid RCC tend to be more responsive to immune therapy than VEGF-targeted therapy, so I would be tempted to find a clinical trial with a novel IO agent. If unavailable, one cou...
How do you manage endocrine therapy in patients on tamoxifen who develop thrombophlebitis but not DVT?
In a patient on tamoxifen, the risk of clot extension into the deep system is higher than average. In such scenarios, the recommendation is to use anticoagulation for at least 6 weeks (consider 3 months if no improvement noted at 6 weeks). Tamoxifen should be held for the first 3 weeks, consider res...
Do you recommend anticoagulation for a splenic infarct in patients with myelofibrosis and splenomegaly?
I generally do not recommend anticoagulation for a splenic infarct in patients with MF and splenomegaly. The situations where I would anticoagulate: ff they have a splanchic vein thrombosis, or clear evidence of embolic disease (i.e., other areas affected in addition to the spleen). However, general...
What is the best treatment approach for fit, young patients with extraskeletal Ewing Sarcoma in the lung?
A thorough staging workup should be completed to ensure there is no subclinical primary tumor and that the lung lesion is not a metastasis. Extraskeletal Ewing sarcoma is treated the same as a primary Ewing sarcoma of bone with dose dense vincristine, doxorubicin, cyclophosphamide (VDC) alternating ...
How do you determine when to give a second CAR-T cell infusion to a pediatric or young adult patient with relapsed/refractory ALL?
Anti-CD19 CAR-T cell therapy has the capacity to induce high rates of clinical response in heavily pre-treated patients for CD19 expressing B-cell malignancies. Among those, B-cell ALL is a poster child for CAR T cell therapy given the propensity for inducing high rates of MRD-negative complete resp...
What systemic therapy would you choose for elderly patients with HER2+ breast CA who have early metastatic relapse (within months) of completing adjuvant trastuzumab/paclitaxel?
Yes, even our frail older patients may have pretty aggressive HER2+ cancers. I am treating a lovely older lady who is on her 6th line of therapy and has responded to everything she's had, so far! We've been working together for about 7 years! Initially, I stuck to pretty standard regimens with dose ...
What is your regimen of choice for metastatic papillary renal cell carcinoma?
My regimen of choice for papillary RCC is cabozantinib given recent evidence. Papillary renal cancer has not had a standard established therapy until recently. Most of the clinical trials in kidney cancer restricted eligibility to clear cell carcinoma component. SWOG 1500 reported results of a rando...