Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you sequence therapy for metastatic NSCLC patient with a BRAF V600E mutation?
In a newly diagnosed patient with metastatic NSCLC that harbors a BRAF V600E mutation, my preferred first line therapy is the combination of Dabrafenib plus Trametinib. My recommendation is based upon the high response rate (65%) of this combination observed in phase II trials. I would inform the pa...
Would you send a gene assay like Mammoprint or Oncotype on a small (<1 cm) lymph node negative lobular infiltrating carcinoma?
I would not, especially if it was low grade and proliferative rate. "Clinical low" patients by MINDACT categorization had excellent prognoses without chemo, although admittedly, this is not specific to patient with lobular histology... Moreover, it is challenging to have enough tissue for a genomic ...
Would you use lapatinib to prevent recurrence of brain mets in a patient with recurrent brain-only mets from HER2+ breast cancer now rendered NED after radiation?
Options for treating a patient like this are quite numerous and could include lapatinib among other possibilities. Lapatinib, especially when combined with capecitabine, showed good response rates in the CNS. Lapatinib has better CNS penetration than other anti-HER2 agents. However, it is important ...
What is your treatment approach to patients with extremity sarcoma with multiple positive regional nodes?
We generally include lymph nodes > 3 cm or multiple lymph nodes in the first echelon area if within a reasonable distance to the primary in the preoperative volume. For first echelon nodes at greater distances from the primary site without in transit involvement, we would separate out the primary CT...
In a patient with ER/PR positive metastatic breast cancer with CNS disease progression on tamoxifen, would you consider AI+ palbo or capecitabine?
The options for treating a patient like this could depend on a number of factors. For example, the number of brain metastases, patient performance status and level of control of extracranial disease at the time of CNS progression. In general, if a patient has good response to the systemic disease, t...
For a patient with metastatic colon cancer, KRAS WT, when would you consider using EGFR (cetuximab, panitumumab) over VEGF (bevacizumab) antagonists as inital therapy?
Aside from obvious, when patients are contraindicated to bevacizumab due to recent surgery or bleeding, clotting, wound healing problems, I would consider first line if left sided colorectal cancer with negative KRAS, NRAS, BRAF. If you look at the survival benefit with Anti EGFR agents in first lin...
What is your approach to a patient with an advanced stage diffuse large B-cell lymphoma treated with chemotherapy alone (with a PET CR) who then develops an isolated CNS relapse?
This is a challenging albeit relatively rare situation. First, I would make sure to complete systemic workup, including MRI of brain/spine, CSF cytology, and PET/CT. I would not consider radiosurgery even for a single brain lesion, as this is ultimately a more diffuse disease process. If patient has...
What chemotherapy regimen would you recommend for a patient with symptomatic cutaneous B cell lymphoma?
This would depend on the subtype and stage. If only cutaneous disease and marignal or follicle center histology then single agent rituximab is best studied. The literature is variable on the # cycles to give, but there is nearly a 100% RR with high CR with follicle center. PCDLBC-LT requires multiag...
Given the sensitivity and prognostic value of the serum free light chain ratio for light chain multiple myeloma, do you continue to check urine studies?
This is a very pertinent and timely question. In fact, there is finally data. Dr. Dejoie et al published in Blood a study comparing the performance of serum and urine measurements in 113 newly diagnosed light chain myeloma patients. Interestingly only 64% of these patients had a measurable urine pro...
What is your next step in management for a patient with immunotherapy induced pneumonitis that does not improve on high dose steroids for 48 hours?
There is an excellent answer to this question from my colleague Dr. @Dr. First Last that can be found here. She provides an overview of the data as well as multiple references.