Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any evidence for efficacy of using a PARP inhibitor in metastatic triple negative breast cancer who progressed on platinum therapy with BRCA-2 variant of unknown clinical significance on molecular testing?
The main recent PARPi trials (OlympiAD, Embraca) enrolled women with known or suspected pathogenic germline mutations so the efficacy in true VUS patients is not known. There are efforts to try and predict the effect of VUS mutations on BRCA function (Woods et al Genomic Med 2016), but we don't know...
Is there a role for any non-cisplatin based adjuvant therapy or radiotherapy (in absence of platinum sensitizer) for muscle-invasive, node-negative bladder cancer after radical cystectomy?
This is a very clinically relevant question that we often wrestle with the optimal management. In the adjuvant space, multiple investigators have looked at alternative adjuvant chemotherapy regimens for patients after cystectomy and deemed cisplatin-ineligible. The most ideal would be carboplatin-ba...
What palliative systemic treatment options (if any) may be considered for metastatic adenocarcinoma of the rete testis?
There is no known effective therapy for metastatic rete testis cancer. I presume the patient is not a candidate for resections of metastatic deposit(s). If we were seeing here we would do NGS to see if there is anything that could be therapeutically exploited. Sorry.
How do you assess the risk of cardiotoxicity from HER2+ agents?
The standard risk factors for cardiac dysfunction from Her2+ therapy are age, prior chest radiation, prior cardiotoxic therapy, baseline LVEF, and co-morbidities such as diabetes, dyslipidemia, obesity, hypertension, atrial fibrillation/flutter, and coronary artery disease. In addition to these, som...
What is your approach to women with early-stage hormone responsive breast cancer intolerant of AI's who want to remain on endocrine therapy but have contraindications to tamoxifen?
Assuming you have tried all 3 AIs along with maximal supportive care for the side effects leading to intolerance and you truly have an absolute contraindication to tamoxifen then you don't have any real proven other options in a postmenopausal patient. Sometimes the patient will quit therapy altoget...
For patients with HER2 positive breast cancer s/p neoadjuvant chemotherapy with TC-HP who did not have a complete pathological response at surgery, is there any evidence to use an anthracycline-based chemotherapy after the surgery?
There isn't large comparative data comparing giving anthracyclines vs not in non-PCR patients. In NEOSPHERE all the patients got adjuvant anthracycline after nonanthracycline therapy. It appeared that patients with a PCR did numerically better than non-PCR patients despite all getting anthracyclines...
Is there a role for retreatment with immunotherapy in patients progressing after initial treatment with immunotherapy for metastatic non small cell lung cancer and who achieve complete or partial response at two years?
The data regarding discontinuation of immunotherapy at 2 years comes mainly from melanoma studies with pembrolizumab. The data in melanoma is strong that therapy can be discontinued, and in these patients the 24-month disease free survival after discontinuation was nearly 90%. The data for NSCLC is ...
What is the preferred palliative treatment regimen for elderly patients with advanced cholangiocarcinoma?
There is very limited data to provide a data driven approach to the management of elderly patients with advanced cholangiocarcinoma. In my clinical experience, gem/cis combinational chemotherapy as given in the ABC-02 trial is well tolerated for most older adults with preserved performance status an...
Is there a difference in the durability of CR based on the dosage of pembrolizumab used in metastatic melanoma?
This a great question and highlights the drug dosing and development process of the use of Pembrolizumab in metastatic Melanoma. In Keynote-002, Pembrolizumab was studied in the does of 2mg/kg and 10mg/kg vs chemotherapy and the CR responses were 2 vs 3% in the Pembrolizumab arms. In Keynote-006, Pe...
Are you considering the use of circulating tumor DNA or circulating tumor cell count to make clinical decisions in the adjuvant setting after colon cancer resection?
Circulating tumor DNA (ctDNA) has become commercially available with several NGS panel sequencing 70-100 genes. It is somewhat of interest in determining resistance to anti-EGFR drugs for advanced disease patients, as transient RAS mutations may emerge and then recede.In the adjuvant setting, one st...