Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Can Oncotype be used in women with ER positive, 1-3 lymph node positive disease with extracapsular extension?
The use of Oncotype assay in 1-3 node positive women is addressed in RxPonder trial in which women with 1-3 positive nodes and oncotype scores of 25 or less were randomized to receive either endocrine versus chemoendocrine. The trial is fully enrolled but the results have been reported as yet. Howe...
How do you manage patients with bilateral renal cell carcinomas?
Bilateral RCC without distant mets should be managed surgically if at all possible (e.g. bilateral partial nephrectomies), assuming adequate residual renal function. Pre-operative TKI to enable partial nephrectomy has been reported in multiple phase 2 trials with some success. If metastatic, then I ...
How would you approach the treatment of resectable NSCLC with a solitary resectable brain metastasis and no other sites of metastasis?
There is a several decade history of curing NSCLC in patients presenting with a solitary CNS metastasis and with resectable lung primary. This has primarily been for patients with N0 or N1 rather than N2 disease. It is unknown whether SBRT would be equivalent to craniotomy. There is, of course, no d...
What would be your second line approach for a patient with MSI-H metastatic colon cancer who progressed on first line chemotherapy?
I would definitely favor nivolumab + ipilimumab in this setting. Although we don't have a randomized comparison, the response rate, duration of response, and PFS reported in CheckMate 142 clearly exceed what we would expect with second-line chemotherapy. This is even more remarkable when you conside...
How would you treat a patient with aggressive metastatic cutaneous squamous cell carcinoma, which is not amenable to surgery or radiation?
This is an interesting question. Recently in the NEJM (July 2018) there was a phase 1/2 study using an anti PD1 agent (cemiplimab) for advanced, unresectable or metastatic cutaneous squamous cell carcinoma. Previously this was a tumor type with no approved therapies and treatment recommendations wer...
Should a patient be given extended endocrine therapy if she was on a lower dose than recommended for part of her treatment?
Two questions here:1. Does she need extended endocrine therapy? Several extended endocrine therapy trials using AI or a switch strategy showed lack of a significant benefit with improving disease free survival (summarized here: https://www.healio.com/hematology-oncology/breast-cancer/news/print/hemo...
What would you recommend as a subsequent therapy for patients with ROS-1 gene re-arrangement after progression on crizotinib?
Clinical trial (entrectinib, repotrectinib) or lorlatinib
When would you consider neoadjuvant immunotherapy for advanced melanoma?
Neoadjuvant immunotherapy is a reasonable if investigational approach to melanoma. The role of neoadjuvant therapy as an investigative approach lies in its ability to give both efficacy information and Biomarker information. We have published encouraging results with interferons 12 years ago, (Mosch...
What imaging surveillance do you do after SABR of oligo lung metastases?
Since these are metastatic patients I would recommend chest CT scans every 3-4 months for the first and second years. Abdomen and pelvis CT scans could also be done depending on the patient and their disease. I do not recommend PET-CT after SBRT for lung metastases or after SBRT for lung primaries. ...
What are your recommendation for vaccines in patients while on immunotherapy?
It's ok to give.