Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach an ER negative, PR positive, Her2 negative breast cancer in terms of hormone manipulation based on PR status alone?
This is a very interesting question. My practice is not to utilize anti-estrogen in true ER Negative /PR positive cases ( after repeating the assay on another tissue sample to rule out a false negative ER assay). EBCTCG meta analysis of randomized trials published in Lancet in 2011 showed only sligh...
Would you consider using a PD-L1 inhibitor after progression on a PD-1 inhibitor for metastatic NSCLC?
We do not have direct evidence to assess this question, but in the absence of data, I have been quite skeptical that switching from a PD-1 to a PD-L1 inhibitor would be an effective strategy. I think that the most direct data that I can offer from studies in which I have been involved is a study of ...
Is it routine to check imaging during or after neoadjuvant chemotherapy for breast cancer to assess for a radiographic response?
I think the issue of checking imaging studies during or after neoadjuvant is only it if will change your management. For example, if you cannot assess clinical response in the breast and axillary during neoadjuvant therapy then imaging might reveal progression, in which you case the patient is heade...
What is the standard of care (if any) for pediatric desmoplastic round cell tumor?
I am an adult oncologist and will defer to a pediatric oncologist if one is available to specifically address the question asked. Multidisciplinary evaluation in a sarcoma center is essential. For adults with this diagnosis, we manage desmoplastic small round cell tumors along the lines of Ewing sar...
How do you approach adjuvant therapy for a resected gastric GIST when the risk for recurrence is discordant between various prediction tools?
For intermediate risk patients, I generally have a discussion with the patient surrounding the risk of recurrence vs the potential toxicity of adjuvant therapy. Some patients will opt for surveillance and others will be more comfortable starting adjuvant imatinib. A nomogram that I find especially h...
How do you monitor patients with metastatic breast cancer?
NCCN Guidelines recommend regular office visits, lab testing, and imaging studies, but there is a wide range of recommendations for the frequency, i.e. 6 weeks to 6 months and these are not based on prospective data. NCCN and ASCO guidelines recommend that metastatic disease be monitored in selected...
Would you use paclitaxel and trastuzumab in ER negative, HER2+ breast cancer with micrometastases in a single node?
Patients with HER2+ disease are doing so well with modern regimens that de-escalation strategies as was done in the APT trial is a goal. However, in that trial virtually all were node-negative (only 6 patients enrolled with micromets) > 90% had tumors no larger 2cm and 2/3 had ER+ disease. So the te...
How would you treat metastatic NSCLC in a non-smoker with bone biopsy showing adenocarcinoma of lung origin but inadequate tissue for mutational panel or PD-L1?
Molecular studies and PDL1 have become standard for patients with advanced/metastatic lung adenocarcinoma. We feel particularly strongly about doing this (molecular studies) in the never smoker, however all adenocarcinomas (and selected squamous cancers) should have this done. Cytology specimens (du...
What is your preferred treatment to ameliorate bone pain from G-CSF?
Loratadine (or cetirizine) used prophylactically before each dose is very effective. There are published cases : https://www.ncbi.nlm.nih.gov/m/pubmed/24664474/ and my experience is this is effective in a vast majority of cases.
What is your approach to the decision to use CPX-351 or standard 7+3 for de novo AML?
CPX-351 is a dual-drug liposomal encapsulation of cytarabine and daunorubicin that delivers a synergistic 5:1 drug ratio into leukemia cells to a greater extent than normal bone marrow cells. It was approved by the FDA in 2017 for the treatment of adults with newly-diagnosed therapy-related acute my...