Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you ever recommend resection only (no chemorads) for a T1N0 anal canal cancer?
Concurrent chemoradiation for SCC of the anal canal was first investigated in the preoperative setting to reduce the rate of recurrence after APR. This ultimately led to the realization that the vast majority of patients could be cured with chemoradiation alone. Since resection in this case necessit...
How do you approach previously treated grade 1 follicular lymphoma now with transformation to a large cell lymphoma?
I believe the question is an important one that has not been addressed by an adequately powered prospective study. These patients are often folded into studies of relapsed and refractory disease. The consensus is that these patients have a poorer prognosis than those with de novo diffuse large B-cel...
How do you treat a patient with widely metastatic, non T790M mutated, EGFR exon 20 insertion mutated lung cancer?
The EGFR exon 20 insertion mutations represent approximately 9% of all EGFR mutations, and affect a similar demographic/clinical group - never/light smokers, adenocarcinoma, tending towards a younger age (Oxnard, JTO 2013;8:179-184). Unfortunately, the data (preclinical and clinical) to date do not ...
Would you use Ibrutinib plus Venetoclax as second line therapy in relapsed/refractory mantle cell lymphoma?
I may consider this for the right patient with Mantle cell lymphoma that has relapsed with TP53 and high risk prognostic score. Even though the data is very exciting it is a single arm study with a small patient cohort, I would want to see a randomized data to make a definitive switch. The CR rates ...
How do you manage patients with locoregional lymph node recurrence after radical cystectomy for muscle invasive bladder cancer?
Recurrent bladder cancer is typically a systemic disease. I would start with cisplatin based chemotherapy first and then add consolidative radiotherapy. There is a small body of literature on surgical consolidation as well. In our single instiution experience patients did very well following radioth...
How do you decide to choose TC vs CMF for HER2 negative breast cancer patients who warrant adjuvant chemotherapy?
There are various modifications of CMF. Most of the data on the efficacy of CMF is based on the "classic" dose and scheduling, i.e. IV MTX and 5-FU on day 1 and 8, and oral cyclophosphamide on day 1-14 of a 28-day cycle. [Historically, this regimen was developed to duplicate the schedule of the high...
Is there any role for additional chemotherapy for a pre-menopausal woman with locally advanced ER+, Her2- IDC, with residual disease after neoadjuvant AC?
Locally advanced higher risk disease should get both AC and a taxane in either the neoadjuvant or adjuvant setting. So for ER+ disease I would give the taxane adjuvantly then move on to radiation and endocrine therapy in this case.
Do you routinely check echocardiograms for patients getting HER2 directed therapy for metastatic breast cancer?
I monitor LVEF with echocardiography at 3 months' intervals. My rationale is that changes in LVEF can then be addressed in real time in an attempt to prevent further cardiac decompensation, symptomatic cardiac events, and discontinuation of Her2 targeted therapy. We’re currently looking at prophylac...
Have you used immunotherapy for NSCLC in a patient with multiple sclerosis?
This is a challenging question. Traditionally patients with immune mediated or autoimmune illnesses were excluded from PD1 or PDL1 inhibitor clinical trials. There is some retrospective data emerging in NSCLC and in melanoma that some patients with autoimmune conditions could be safely treated with ...
Which systemic therapy would you use to treat a poorly-differentiated round cell sarcoma with CIC-DUX4 gene fusion?
A patient with a sarcoma such as this should be evaluated at a multidisciplinary sarcoma center, including pathology review. I would favor treating with a Ewing sarcoma regimen as these can be very aggressive tumors. A small series recently reported at the annual CTOS meeting of CIC rearranged small...