Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you monitor patients with metastatic breast cancer?
NCCN Guidelines recommend regular office visits, lab testing, and imaging studies, but there is a wide range of recommendations for the frequency, i.e. 6 weeks to 6 months and these are not based on prospective data. NCCN and ASCO guidelines recommend that metastatic disease be monitored in selected...
Would you use paclitaxel and trastuzumab in ER negative, HER2+ breast cancer with micrometastases in a single node?
Patients with HER2+ disease are doing so well with modern regimens that de-escalation strategies as was done in the APT trial is a goal. However, in that trial virtually all were node-negative (only 6 patients enrolled with micromets) > 90% had tumors no larger 2cm and 2/3 had ER+ disease. So the te...
How would you treat metastatic NSCLC in a non-smoker with bone biopsy showing adenocarcinoma of lung origin but inadequate tissue for mutational panel or PD-L1?
Molecular studies and PDL1 have become standard for patients with advanced/metastatic lung adenocarcinoma. We feel particularly strongly about doing this (molecular studies) in the never smoker, however all adenocarcinomas (and selected squamous cancers) should have this done. Cytology specimens (du...
What is your preferred treatment to ameliorate bone pain from G-CSF?
Loratadine (or cetirizine) used prophylactically before each dose is very effective. There are published cases : https://www.ncbi.nlm.nih.gov/m/pubmed/24664474/ and my experience is this is effective in a vast majority of cases.
What is your approach to the decision to use CPX-351 or standard 7+3 for de novo AML?
CPX-351 is a dual-drug liposomal encapsulation of cytarabine and daunorubicin that delivers a synergistic 5:1 drug ratio into leukemia cells to a greater extent than normal bone marrow cells. It was approved by the FDA in 2017 for the treatment of adults with newly-diagnosed therapy-related acute my...
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...