Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat oligometastatic NSCLC (brain and bone) with Non-V600E BRAF mutations?
I would treat with chemo-pembro. Down the road, MEK inhibitors is a choice.
How would you approach metastatic NSCLC (adenocarcinoma without brain mets) with PD-L1 >50% and BRAF V600E driver mutation?
I would start with dabrafenib + trametinib based on what we know from available relevant trials and the literature. -- Response rate for dabrafenib + trametinib as 1st-line therapy for people with BRAF V600E NSCLC was 64%. -- Response rate for pembrolizumab as 1st-line therapy for people with NSCLC ...
Are there any special considerations for treating CML in the very elderly, greater than 85 years old?
When approaching older patients with CML it is important to consider comorbid conditions, medications, organ function, and potential toxicity of therapy. This approach is not that different than it would be for younger patients. However, older patients are more likely to be on more medications or to...
What systemic therapy would you consider, if any, for an isolated but multifocal CNS recurrence of HER2+ HR negative breast cancer treated with local therapy (>4 lesions treated with resection and SRS)?
There is not an agreed-upon standard approach, nor am I aware of definitive data supporting one approach over another. My preferred approach to managing isolated CNS relapses that are treated locally with no visible systemic disease is to do trastuzumab plus a TKI with no chemo (like EGF104900 regim...
Would you consider adjuvant chemotherapy for concurrent early stage NSCLC in ipsilateral separate lobes, or do you consider them as separate primaries?
This situation can arise when a patient undergoes lobectomy for primary lesion but has sublobar/wedge resection of a separate nodule in a different lobe with pathology showing the same histology. If both are very early stage and no nodal involvement or other indications for adjuvant chemotherapy, I ...
Would you start neoadjuvant treatment with immunotherapy or BRAF/MEK inhibitors in a patient with a large regional inoperable BRAF V600E positive melanoma (IIIC)?
I prefer to start with BRAF inhibition, as the response rate is quite high, then ask the surgeon to complete the surgical resection after 3 to 6 months of therapy if the patient has a response, and usually offer adjuvant immunotherapy afterwards. If the patient does not respond, I would switch to ip...
How would you manage a patient with history of clear cell RCC >4 years ago who has a solitary oligometastatic brain lesion that is asymptomatic and too small for stereotactic radiation?
I've not encountered a CNS lesion too small for SRS. Sometimes, very small abnormalities are uncertain and are watched, but usually, they are big enough to be diagnostic and treated. If that's the only site of disease, I would do SRS then observe that patient.
Do you offer surveillance brain imaging for patients with EGFR+ NSCLC, stable systemic disease on TKI, and no history of metastatic brain disease?
There are very few data based on randomized trials but we know that the brain is a major site of progression even with osimertinib so I get a brain MRI every 6 months.
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
What maintenance treatment would you recommend for Ph positive ALL following Hyper-CVAD, transplant eligible or ineligible?
While ABL kinase inhibitors (TKIs) are commonly recommended as maintenance post-transplant in Ph+ ALL, the data supporting this practice are relatively soft. Position statements from expert panels convened by EBMT (Giebel et al., PMID 27309127) and ASTCT (DeFilipp et al., PMID 31446198) both general...