Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is carboplatin/pemetrexed as effective as cisplatin/pem in treatment of unresectable malignant pleural mesothelioma in a patient with contraindication to cisplatin?
The combination of carboplatin/pemetrexed instead of cisplatin/pemetrexed is definitely reasonable in older mesothelioma patients and/or patients with comorbidities or concerns about poor tolerability to cisplatin. At least three phase 2 non-randomized studies evaluated the combination of carboplati...
When in the treatment algorithm for pancreatic/GI NET do you recommend interferon?
Our team uses interferon only occasionally and generally later in the algorithm. With randomized data to support agents with favorable toxicity profiles, such as somatostatin analogues, everolimus, and PRRT, these options are frequently preferable.However, older randomized data (Kolby et al., Br J S...
How do you manage a patient with metastatic prostate cancer who does not acheive a PSA response to upfront ADT?
First and foremost, of course, confirmation that androgen deprivation (ie testosterone <50 ng/dl) has been achieved should be obtained. While uncommon, primary resistance to a particular hormonal agent can occur. In this case, an alternate agent can be tried (eg switching from an LHRH-R agonist to a...
How would you treat a pregnant woman in the third trimester with locally advanced, hormone receptor positive, HER2 positive breast cancer?
Given good amount of safety data on anthracycline therapy during pregnancy, favor doxorubicin cyclophosphamide x 3-4 cycles (depending on time of delivery) given every 3 weeks without peg-filgrastim support. With less data with growth factor support, lean toward avoiding in this situation. Will avoi...
Is concurrent intrathecal therapy necessary with HD-MTX for CNS lymphoma?
Generally, high dose methotrexate has high penetration into the CSF so you do not need to give concurrent intrathecal therapy. The only time you might consider it is if they still have persistent disease in the CSF despite the high dose methotrexate. The approach does not change for primary vs secon...
How would you treat a patient with head and neck squamous cell carcinoma and adverse features with borderline renal function in the adjuvant setting?
In the postoperative setting, bolus-dose cisplatin (80-100 mg/m2) every 21 days with radiation is the preferred treatment for patients with positive margins or extranodal extension. If patients cannot tolerate high-dose cisplatin, weekly cisplatin can be considered. In one randomized study of SCCHN ...
Do you offer pembrolizumab monotherapy or carbo-pemetrexed-pembrolizumab to a patient with Stage IV large cell NSCLC with PD-L1 of 80% and KRAS+STK11 mutation?
This is a good question. My opinion is first that the KRAS is irrelevant and only studied because of the mouse model. The entire effect is from LKB1, independent of KRAS. Second, that this has not been tested in any of the randomized trials looking at IO vs. IO/chemo vs. chemo, so its predictive abi...
Is there any evidence to treat the primary breast tumor with local therapy after a radiographic CR with systemic therapy for stage IV disease?
Resection of the primary breast cancer in setting of stage IV is the question in a number of prospective randomized trials and the answer we have to date there is no overall survival advantage, except in the very small number of patients with a solitary bone mets. However, we know HER2 positive wome...
Is there any reason to switch endocrine therapy after a patient undergoes bilateral oophorectomy?
In my opinion, in the absence of progressive disease, I would maintain this young woman on tamoxifen as long as there were not progressive disease and the tamoxifen was well tolerated. Now that she has had an oophorectomy, and has been rendered menopausal, there will be many options when progressive...
How do you approach an ER negative, PR positive, Her2 negative breast cancer in terms of hormone manipulation based on PR status alone?
This is a very interesting question. My practice is not to utilize anti-estrogen in true ER Negative /PR positive cases ( after repeating the assay on another tissue sample to rule out a false negative ER assay). EBCTCG meta analysis of randomized trials published in Lancet in 2011 showed only sligh...