Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you modify the duration of adjuvant therapy for patients with colon cancer who have undergone metastectomy and primary tumor resection?
For de novo oligometastatic colon cancer that is amenable to a potentially curative approach, I aim for 6 months of perioperative chemotherapy with fluoropyrimidine and oxaliplatin. Since irinotecan, anti-EGFR monoclonal antibodies, and bevacizumab do not treat micrometastatic disease effectively, t...
Beyond PD-L1, when would you consider additional molecular testing (EGFR, ALK1, ROS1) for patients with squamous cell lung cancers?
I mainly test patients with squamous cell lung cancer if they are never, remote or light smokers, or if the diagnosis was based on a small biopsy and pathologist was not 100% sure squamous cell was the histology. Other experts would argue to test all patients regardless of histology for mutations as...
What is your approach to treating early stage EBV-positive diffuse large B-cell lymphoma of the elderly after a CR to systemic therapy?
EBV+ diffuse large B-cell lymphoma of the elderly, which typically affects apparently immunocompetant individuals > 50 y/o, was a provisional diagnosis in the 2008 edition of the WHO classification system. EBV+ DLBCL has been recognized in younger patients which led to a revision in the 2016 classif...
Do you use absolute WBC count or doubling time to determine whether to start treatment for early stage CLL?
In my view, the pace of disease is a more relevant indicator of the need for treatment than any absolute WBC count. Observations over time usually make it clear when treatment is needed. Several studies have shown that early intervention is not associated with improved survival, though it must be ac...
Do you use an alternative dosing regimen for CDK4/6 inhibitor in patient with benign ethnic leukopenia?
It is known that patients of african descent have a lower white blood counts (Ethnic Neutropenia). Despite the lower WBC and Neutrophil count, there is no evidence of increased risk of infection. In this setting i usually do not lower the dose, but set a lower cut-point for dose change, or only chan...
Do you pursue testing for ERBB2 mutations in patients with metastatic breast cancer who are clinically HER2-negative by IHC and FISH?
I generally will consider NGS in women with progressive TNBC or progressive ER positive, Her2 negative MBC that has progressed through at least 3-4 hormonal therapies and/or chemotherapies. I find that about 5-10% of these women have mutations in the tyrosine kinase domain of Her2 (a bit higher than...
How would you treat a patient with a small (<0.5 cm) node negative, grade 3 BRCA1 mutated triple negative breast cancer?
In the recently published POSH trial by Copson et al (Lancet Oncology), the investigators examined outcomes in a cohort of women age 40 or younger newly diagnosed with breast cancer. In the overall cohort of 2733 women, 12% had BRCA mutations. After a median follow-up of 8.2 years, there was no sign...
How would you treat a post menopausal woman with newly diagnosed PR positive, ER negative and Her 2 negative metastatic breast cancer with germ-line BRCA2 mutation?
Based on current evidence the outcome of patients with germline BRCA 1 or 2 mutation who developed breast cancer is similar to patients with breast cancer who do not carry germline BRCA mutations. I would use similar judgement in regards to decision for different systemic therapy as I would if the p...
When treating a patient with multiple myeloma with bortezomib, how do you decide between subcutaneous vs intravenous dosing?
Due to the markedly increased risk of of peripheral neuropathy, the standard of care worldwide is to utilize subcutaneous bortezomib. There really is no medical indication to prefer IV over SQ. The issue of weekly versus biweekly bortezomib is controversial. The FDA indication is for biweekly on day...
Would you consider aggressive presentation of multiple squamous cell carcinomas of the skin an indication for treatment of CLL?
In general, no. The reason is that the many squamous cell carcinomas are a manifestation of immune dysfunction. Historically, when all the treatments were chemo-based, immunity would be if anything, temporarily worsened. Then, even in people in CR, immunity wasn't always restored. For example, patie...