Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach therapy for a patient with high-grade sarcoma who is unable to tolerate systemic cytotoxic chemotherapy, but whose tumor revealed NRAS G12A, BRCA1, and MET amplification?
I would try weekly cisplatin. Cisplatin is the best drug there is vs tumors with BRCA1 polymorphisms. You need reasonable kidney function for cisplatin but bad liver does not mean bad kidneys. Platinum is safe, with less hematologic toxicity than other chemos. You don't need a port. Weekly cisplatin...
Would you consider adding HER2 targeted treatment to chemotherapy for a patient with locally advanced, HER2+ rectal cancer who is going to have total neoadjuvant treatment?
There are approximately 3-5% metastatic colorectal cancer patients who have HER2 amplification detected by either IHC, FISH, or by NGS that includes an RNA test (Loree et al., PMID 29718453).Clinical trials showed convincing evidence that HER2 targeted treatment is effective for HER2 positive metast...
How do you approach the management of a patient with extensive small cell lung cancer who has progressed on third-line therapy, with borderline functional status, complicated by paraneoplastic CNS syndrome?
Given the overall poor prognosis of small cell lung cancer, I would be inclined to start with a goal of care discussion. Many clinical trials still require ECOG PS 0-1 and I do not believe in "fudging" PS for borderline patients to enroll on a trial. I may consider single agent chemotherapy - lurbin...
How would you approach immunosuppression for patients with severe aplastic anemia who are not transplant or ATG candidates?
There are relatively few alternatives. One is just supportive care with transfusion, antibiotics, etc. Many patients will adapt to low Hb and do ok with low platelets and do not require therapy. A calcineurin inhibitor alone or with eltrombopag can also be used - the response rate is not as good as ...
With advancing and new therapies emerging for metastatic HER2+ breast cancer, how does one decide between options for third line therapy at time of progression?
Barring any contraindications, tucatinib would be my preferred third line after progression on traz/pertuz and ado-traz.
Which chemotherapy regimen would you recommend for locally recurrent TNBC several years after therapy with docetaxel + cyclophosphamide for four cycles?
Typical regimens for TN breast cancer include TC, AC-T, AC-TCb +/- Pembro, and CMF. The CALOR data supports using adjuvant chemotherapy for recurrence. Details that I would usually consider when selecting a regimen in this setting include: Does the patient have residual side effects or co-morbiditie...
How would you manage asymptomatic brain metastases from testicular non-seminomatous germ cell tumor with a choriocarcinomatous component?
Despite the obvious issue of the blood brain barrier, BEP chemo alone (or VIP) is sufficient for treating such patients. We would, however, repeat head MRI just before starting second course of cisplatin combination chemotherapy to ensure appropriate response.
How late after completion of adjuvant capecitabine and radiation would you consider adjuvant olaparib for a patient with gBRCA mutated TNBC?
OlympiA enrolled patients up to 12 weeks post adjuvant chemotherapy. So technically, this patient is within the window, but just barely. For a lower risk patient (e.g. small T1-T2N0, pCR after neoadjuvant therapy), I would probably not consider it one year after completing therapy. However, for a hi...
How would you treat a patient with urothelial cancer and 25% plasmacytoid variant who has a solitary recurrence in rectum 1 year after neoadjuvant chemotherapy and radical cystectomy?
Plasmacytoid urothelial carcinoma has a very high tendency to develop peritoneal carcinomatosis. And although on scan there could be solitary occurrence, on exploration, may be able to see more peritoneal involvement. Thus, systemic therapy would be a more appropriate strategy to treat. Diamantopoul...
What regimen would you recommend for a younger, fit, transplant eligible patient with relapsed IDH1 positive AML?
If there was only one answer! The decision revolves around co-occurring cyto and molecular genetic abnormalities (in addition to IDH1) and the duration of remission in first CR. In general, IDH mutant AML - without other high-risk genetic lesions - is very responsive to all of our treatments whether...