Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider a trial of pembrolizumab in a patient with metastatic urothelial carcinoma progressing on atezolizumab?
I dont think that would make sense. The monotherapy data for all the CPI are very similar. IMvigor 211 was a negative trial purely on a "trial design" issue. The ITT population was positive favoring atezolizumab over chemotherapy. I would consider a CPI after a trial of chemotherapy or radiation whi...
How are you incorporating abscopal radiation into your practice for metastatic NSCLC?
There is not enough evidence to guide our daily clinical practice about radiation abscopal effect off protocol. However, in stage IV NSCLC, we can use RT to: 1. Eliminate/control chemo or target therapy resistant or persistent primary and oligo-metastases 2. Concurrent SABR with targeted therapy for...
How do you decide on the optimal neoadjuvant regimen for locally advanced GEJ cancer?
There is no randomized trial comparing the neoadjuvant chemo (MRC OEO2 or OEO5 trials) and neoadjuvant chemoradiation (CROSS trial) approaches in this setting. That being said, it's clear that chemoradiation produces more pathologic complete responses. Non-randomized data from MD Anderson (Swisher e...
Is there a role for trastuzumab in the preoperative chemoradiation regimen for HER2 + esophageal adenocarcinoma (cT3N0)?
Outside of a clinical trial, I would not add trastuzumab to neoadjuvant chemoradiation at this point. RTOG 1010 will shed light on the utility of trastuzumab in this setting.
In a patient with resected NSCLC whose only site of relapse is CNS (treated with WBRT or SBRT), would you also start systemic therapy with erlotinib/afatinib if the patient was found to be EGFR positive?
Would not do WBRT. if there are more than a dozen would treat with osimertinib as it crosses the BBB. If there were just a few and PET negative would trreat with SBRT and follow with ctDNA, brain MR and chest CT
Based on the FLAURA trial, would you consider using osimertinib firstline in EGFR-mutated NSCLC?
Yes I would. The primary reasons are that the drug is not only has better PFS but also is better tolerated and has CNS activity. There remain several questions, 1. What therapy to choose in patients who progress after front line osimertinib? 2. Does the drug only work in the 50-60% of the patients w...
Would you consider concurrent chemoRT for unresectable bladder adenocarcinoma?
The simple answer is YES. If unresectable then follow the established treatment paradigm of maximal TURBT followed by ChemoRT. Platinum based regimens are typically the standard with good evidence for alternative schedules such as 5FU/mitomycin or Gemcitabine (low dose). This is s potentially curati...
How do you handle the situation where a curative-intent patient unexpectedly passes away while under treatment?
As many of the patients we treat are older and have numerous co-morbidities, this is not that rare an occurrence. Of course, we would presume to avoid treating patients with curative intent if it is readily apparent that their life span will be short due to other non-malignant illness. That said, I ...
For NSCLC patients with limited diagnostic tissue that is insufficient for genetic testing, do you offer repeat biopsy (of accessible site), blood based testing, or both to evaluate for actionable driver mutations?
If a patient has insufficient tissue for molecular testing, I will immediately send a liquid biopsy while simultaneously setting up a repeat biopsy. Our blood-based testing returns within 5-7 days. If a driver mutation is found on liquid biopsy, I will cancel the repeat tissue biopsy. If no driver m...
How would you approach patients with EGFR mutation positive (exon 19) NSCLC who rapidly progress on front line EGFR inhibition with first generation TKI at first imaging?
This is a difficult challenging situation. I usually repeat tissue biopsy or at least order a liquid bx, confirm that in fact they did have the EGFR mutation and assess for the T790M. I do consider switching to osimertinib if they have the T790M and this was not the EGFR TKI they were on. However ch...