Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your experience with liposomal-encapsulated daunorubicin and cytarabine (CPX-351) for first line treatment of therapy-related AML or AML with myelodysplasia-related changes in elderly patients?
Our center has been administering CPX-351 to outpatients for the last few months. We monitor the patient closely in the first week for tumor lysis. Since the neutropenic fever rate is the same as 7&3 we have need to admit many of the patients at some point in the cycle but overall it has gone very w...
Would you consider primary tumor resection in a patient with oligometastatic colon cancer with complete metabolic response after 6 months of initial chemotherapy?
Do you give 3 or 4 cycles of HiDAC during consolidation for good/intermediate-risk AML without an available allotransplant donor?
This is a complicated question because risk stratification of AML has rapidly transitioned from including clinical presenting features (age, WBC, co-morbid diseases) with cytogenetics/select mutations to now multiple mutations and other biologic features. An example is core binding factor AML with a...
How do you approach a lung malignancy with a single pleural nodule near a primary?
This is a relatively rare scenario. For example, in a Korean series of almost 4,000 patients undergoing surgery for NSCLC, 78 (2%) were found to have unexpected pleural seeding intra-operatively (Thorac Cardiovasc Surg 2018;66:142). A small number of surgical reports suggest, that when limited seedi...
What do you do for patients with HR+ inflammatory breast cancer who do not achieve a pCR with neoadjuvant chemotherapy?
I assume the patient in this question is HER2 negative. Inflammatory breast cancer is rarely HR+, HER2-, but for HR+ HER2- invasive breast cancer who do not achieve pCR with neoadjuvant chemotherapy, I would recommend to maximize the benefit of adjuvant hormone therapy.The patient certainly could jo...
How would you approach patients with ALK-positive metastatic NSCLC who progress on crizotinib and subsequently alectinib?
Ideally, I would biopsy the recurrence to determine if there is a defined resistance mutation that might be targetable by brigatinib or lorlatinib. I always try to maintain TKIs as long as possible. Dose escalation might be effective, but would not be my first choice. If none of these are options, r...
How do you approach adjuvant therapy in patients who have a poor clinical response to neoadjuvant endocrine therapy?
Clinical response rates to neoadjuvant endocrine therapy vary from 40-60% in ER-enriched tumors. Pre and post-treatment PEPI score is shown to be prognostic. It is currently unknown what is best to do for women who do not respond well clinically, or for those who have a high ki67 and/or high PEPI sc...
How would you treat a patient with high-volume metastatic prostate cancer who has asymptomatic biochemical relapse after having a good response to upfront docetaxel?
If the patient is asymptomatic or minimally symptomatic and now castrate-resistant, I would start with sipuleucel-T. Based on the PSA quartile data (Schellhammer et al 2013) and in line with current NCCN guidelines and supportive clinical and preclinical data, immunotherapy should be used as early a...
How would you approach a patient with smoldering myeloma that has a quickly rising and very high M-spike (6 g/dL range)?
The level is very high and worrisome for tumor lysis syndrome and cytokines related symptoms. I would do a bone marrow biopsy first and check free light chain assay. This may confirm the diagnosis of symptomatic myeloma. Also bone imaging study to find any lesions. Once you decide to treat I would ...
Do we have any data on sequencing of up front therapies for patients with high PD-L1 and targeted mutations?
Patients with EGFR and BRAF mutations or ALK and ROS1 fusions should receive 1st line approved TKI therapy and second line approved TKI therapy for EGFR and ALK. Checkpoint inhibitors should be used only after TKIs even if PD-L1 expression is high. For patients with PD-L1 expression >50%, it is not ...