Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does concurrent brain and systemic progression alter your choice of systemic therapy for patients with metastatic SCLC with early progression on chemoimmunotherapy and WBRT?
This is a challenging situation as is expected when treating most patients with ES SCLC. If I give a patient carboplatin with etoposide and a checkpoint inhibitor and they progress shortly thereafter, the standard treatment options are limited. They include single agent chemo such as topotecan, lurb...
In addition to ADT, how would you treat Gleason 8, pure ductal prostate adenocarcinoma with oligometastatic disease?
Based on the available data and knowledge, it is difficult to answer this question definitively.Although prostate ductal adenocarcinoma (PDA), was first described more than 50 years ago and its behavior as an aggressive variant is increasingly being recognized, evidence-based management of PDA is no...
What chemotherapy backbone will you use with pembrolizumab in the neoadjuvant setting for triple negative breast cancer?
I don't have an answer to this, but just opinions. There are several decisions that we will need to make regarding how to best use immunotherapy, unfortunately without much data to guide us:1) What chemo backbone to use?2) Do we really need to continue pembro adjuvantly? If so, in whom? Everyone? On...
Would you consider PRRT re-treatment in a patient with a well differentiated NET previously treated with 4 cycles of PRRT?
Yes, but only for highly selected patients. Might consider discussing retreatment with PRRT (R-PRRT) in those who: 1. Derived good response (or prolonged stable disease) with prior PRRT and,2. Don't have better options available (for example, would not do R-PRRT before CapTem, afinitor, sutent in pN...
What first line treatment would you consider for a patient with stage IV gastric cancer that is HER2 negative and MSI-high?
For a patient with MSI-H, HER2 negative metastatic gastric cancer, PD1 blockade with pembrolizumab (pembro) would be my first choice. The KEYNOTE-062 data support the efficacy of pembro in this setting [Shitara et al., PMID 32880601].The phase 3 KEYNOTE-062 study randomized patients with untreated, ...
Would you give adjuvant therapy for a urothelial carcinoma T2 on TURBT but pTis at margins on cystectomy?
No, this patient would be followed by active surveillance based on NCCN guidelines, e.g. visits, labs, urine cytology, CT chest, CT IVP; would pay attention for any symptoms to upper tract and urethra that may trigger further evaluation. Would discuss with Urologist & Pathologist about the case, the...
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
What systemic therapy would you offer for a local, unresectable relapse of a mixed acinar neuroendocrine carcinoma of the pancreas?
This is a very interesting question. I agree with the overall discussion with some points that need to be clear: Did the pathology show mixed acinar and NEC with >30% of each component? or just acinar with NE features? I agree the data about MANEC is very limited and exclusively retrospective. What ...
For patients with triple negative breast cancer, currently undergoing neoadjuvant dd AC, would you consider adding pembrolizumab to weekly paclitaxel based on recent KEYNOTE-522 and continue as adjuvant?
I think the decision should be informed by the degree of response to AC and initial bulk of disease at presentation. In patients who complete the AC portion and still have clinical evidence of substantial residual disease, I would absolutely consider adding pembrolizumab and carboplatin to weekly pa...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.