Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you treat metastatic, wild-type GIST?
Majority of these are SDH deficient. For these patients, if a clinical trial is available, that would be preferable. From a SOC standpoint, EU investigators have data on Regorafenib. For the rare WT GIST with B-raf mutation or NTRK fusion, appropriate targeted therapy would be indicated.
What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?
Despite the quantum improvement in complete surgical resection, pathologic complete remission, and overall survival rates in S9416/INT-0160 (the trial that established trimodality chemoradiation followed by surgery as the standard of care for superior sulcus NSCLC almost 2 decades ago), distant recu...
What is your preferred adjuvant therapy for a patient with triple negative breast cancer and has a BRCA germline mutation who had minimal to no response to neoadjuvant chemotherapy?
The vast majority of OlympiA patients had both anthracycline and taxane therapy. Very few had less than 6 cycles of chemo or only one of the two agents. For this case, I would try to do 4 cycles of dose dense anthracycline treatments then adjuvant olaparib for 1 year.
For patients receiving outpatient venetoclax/azacitidine who develop profound neutropenia with ANC <200, do you admit for monitoring during the nadir in the absence of fever?
I don't think I would admit these patients. My recommendation would be to monitor temperature daily or feel febrile and let the clinic know if they have any symptoms of localizing infection. The NCCN and IDSA guidelines talk that only neutropenic patients with fever, even amongst those who have the ...
Would you consider a PARP inhibitor in the treatment of a PARP inhibitor naïve platinum resistant recurrent ovarian cancer with LOH/HRD?
These are challenging scenarios and with increasing PARP use in the upfront setting, especially (likely) in the LOH/HRD patients I suspect this clinical scenario may become less frequent in the future. For now, it's appealing to suggest that LOH/HRD scores as a biomarker can be examined in a vacuum ...
Would you consider adjuvant chemotherapy in the management of retroperitoneal leiomyoscarcoma who did not respond to neoadjuvant doxorubicin/dacarbazine?
If pre op ADIC failed and the RP LMS is completely resected with NED, I would just pursue close observation.
How would you treat a patient with T4N1M0 GEJ adenocarcinoma with local progression after concurrent chemoRT who still has resectable disease?
This is a tricky but thankfully rare scenario.My answer depends on the nature of the local progression. The more favorable situation involves local persistence of the primary tumor with a modest increase in locoregional lymph nodes. This situation would essentially represent a lack of response to ch...
Would you consider CAR-T therapy without autologous transplant in a patient with multiple myeloma whose best response to induction therapy is a partial response?
Excellent question that will be even more pressing in ~2024 (maybe earlier!) as we get more data and possibly more FDA/insurance approvals here. For now, the only way to get second-line CAR-T for inadequate response to frontline induction is on a clinical trial - and several such single-arm trials a...
Would you offer adjuvant capecitabine in a patient with nasopharyngeal carcinoma who has had cisplatin - gemcitabine induction followed by chemoradiotherapy with cisplatin?
There are now two randomized, published studies in patients with locally advanced nasopharyngeal cancer whereby capecitabine is administered in the adjuvant setting [1], [2]. Both studies demonstrate adjuvant capecitabine improves failure free survival or local control of disease. The combination of...
Would you provide the KEYNOTE-522 regimen for a patient with ER low, PR+, HER2- stage IIIb breast cancer?
I think it is reasonable to use the KEYNOTE-522 regimen for a patient with stage IIIB breast can with a tumor that is ER-low (<10%), PR+ and HER2-negative, but with many caveats. Both biological and clinical outcomes data suggest that such cases are closer to HR-negative (as is ER-/PR+ disease). (1,...