Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
If a patient with a germ cell tumor has such an event thrombotic events on BEP, is it safe to re-challenge with BEP therapy?
If a patient has an acute thrombotic event, the patient would subsequently be treated with an anticoagulant. These events are most commonly venous thrombi or thromboembolisms but arterial thrombotic events also occur. If the patient is appropriately anticoagulated based on the specifics of the event...
What would be your choice and duration of adjuvant therapy for a perforated MSI-H stage II (T4N0) colon cancer?
There are no data of which I am aware which directly address this situation. Although patients with stage II MSI-H tumors generally have an extremely favorable prognosis, the perforation is worrisome. I would not be opposed to giving six months of adjuvant FOLFOX in this setting as long as the patie...
Is a CLL FISH panel sufficient to aid in treatment decisions in CLL or is p53 sequence analysis also needed?
At a minimum, patients should undergo IGHV mutation analysis as well as testing for deletion of 11q and 17p prior to treatment initiation. However, testing for a TP53 mutation is ideal. While many patients with TP53 mutations will have a concomitant deletion 17p, this is not always the case. Given t...
How would you treat metastatic squamous esophageal carcinoma that is HER2 negative?
In general we would not check HER2 status in squamous cell tumors of the esophagus. I think FOLFOX would be a reasonable first line regimen. Others would be cisplatin with 5FU. There is no standard of care first line regimen. Another reasonable option would be carboplatin with paclitaxel.
How do you interpret and utilize PSA values in patients on dialysis?
There appears to be no clinically relevant impact on total serum PSA, whereas free PSA and % of total can be impacted in a membrane type-dependent manner to where % free PSA is of less utility for screening. Thus, total serum PSA seems reasonable to continue as marker of biochemical control post-tre...
Do you ever start immunotherapy along with WBRT in patients with PDL1 >50% metastatic NSCLC with significant visceral tumor burden in addition to symptomatic brain mets?
The general rule in the era of chemotherapy has been to hold concurrent therapy in the context of palliative radiation--in particular whole brain radiation--due to added side effects. These principles have shifted to some extent in the context of targeted therapies and checkpoint inhibitors as exper...
Do you omit anthracyclines in triple positive breast cancer?
The BCIRG 006 trial is relevant for all Her2 positive disease, both ER positive and ER negative. Depending on the risk profile of the patient (T2 disease and beyond), I give TCHP x 6 as neoadjuvant therapy per Neosphere and Tryphanema. For T1cN0 disease that is ER negative, I give adjuvant TH x 12, ...
What is your preferred front line regimen for metastatic squamous cell NSCLC that is PD-L1 and driver mutation negative?
I believe each are acceptable options. I have generally been using carboplatin and weekly paclitaxel fairly commonly. This regimen is based on Quoix, et al Lancet trial. This study was in elderly patients. I find this very well tolerated with low chances of cytopenias, alopecia. If I have concerns a...
Do you consider alternate therapy with a different anti-PD1 agent after a patient responds to an anti-CTLA4 +/- anti-PD1 agent but develops serious side effects?
The short answer is no. Pembro and Nivo are essentailly the same drug and in all the studies, once the patient has developed grade 3 toxicity the treatment is complete because further dosing will result in even more severe toxicty. The only exception is for endocrinopathies which can be managed with...
Are you ordering EGFR testing on all patients with NSCLC after complete resection in light of ADAURA?
Prior to FDA approval of adjuvant osimertinib, our team had not been ordering molecular diagnostics on people with stage I-III NSCLC as we viewed such testing as a poor use of medical and financial resources. About 70% of people with resected stage IA NSCLC will not recur, so there will never be a n...