Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How will the final overal survival results of PALOMA-3 affect your practice?
I will generally give a trial of first line endocrine therapy with an AI if endocrine-sensitive disease, and reserve Paloma-3 regimen to second line. Endocrine sensitivity can be inferred clinically by disease course (late relapse, recurrence off adjuvant endocrine therapy, asymptomatic status/or mi...
How often are you recommending adjuvant pembrolizumab for resected stage IIB/C melanoma patients?
Will refer to the results from the KEYNOTE-716 trial:The data cutoff for the analysis (in January 2022), median follow-up was 27.4 months (interquartile range = 23.1–31.7 months). Pembrolizumab significantly improved distant metastasis–free survival vs placebo (hazard ratio [HR] = 0.64, 95% confiden...
Do you offer nivolumab for metastatic HCC in the second line or if sorafenib is intolerable?
Using nivolumab in second line if the patient cannot tolerate sorafenib is appropriate; the regorefanib RESORCE trial had selected patients who tolerated sorafenib at a minimum dose of 400 mg daily for 20 of the 28 days prior to study entry.The challenge is the child pugh C status of the patient. We...
How do you discern between pseudo-progression or hyper-progression in patients with NSCLC or cancers treated with immune checkpoint inhibitors?
What is the next step in management following surgical resection of a primary adenoid cystic carcinoma of the lung?
Primary lung adenoid cystic carcinoma is quite rare, and limited data exist to guide treatment. Often these tumors arise centrally or in the trachea, but can occur in the lung parenchyma. It is important to ascertain whether the tumor is truly of primary lung origin vs a metastasis, so ENT evaluatio...
Do you ever consider debulking abdominal/pelvic metastatic breast cancer with HR positive disease?
This question does come up occasionally, more often from patients themselves and trainees. The only time when I have considered (or recommended) a debulking surgery was in the setting of big bulky ovarian masses in the absence of significant visceral disease elsewhere. One reason for doing that is t...
Would you consider neoadjuvant endocrine therapy instead of chemotherapy for a pre-menopausal patient with a node-positive, ER+PR+, lobular breast cancer?
You can consider neoadjuvant endocrine therapy (NET) for classical strongly ER/PR expressing lobular cancers in certain cases where there is a desire to delay surgery or the patient is not a candidate for chemotherapy. Usually the duration of therapy is for around 6 months as long as the patient is ...
How would you treat a patient with metastatic neuroendocrine carcinoma of the gallbladder with early relapse after platinum doublet?
By describing the tumor as a Neuroendocrine carcinoma one implies that the tumor is poorly differentiated and high grade. This is often described as extra-pulmonary small cell lung cancer or high grade GI NEC. There are no standard second line regimens. Options are to treat similarly to a small cell...
Do you consider multifocal disease an indication for chemotherapy with trastuzumab in patients with microinvasive Her2+/HR- breast cancer?
Not necessarily those with just 2 or 3 foci of microinvasive disease, but I am concerned when a patient has multiple (though I'm not sure if the number is 4 or 7 or 10) foci of microinvasion within a sizable area of high-grade, ER- DCIS, especially when the pathologist says that there are too many f...
What first line treatment would you choose for stage IV adenocarcinoma of lung with ALK gene rearrangement and PD-L1 TPS 95%?
If you follow FDA labels, you cannot use first line pembrolizumab on a patient with EGFR or ALK aberration unless they have failed targeted therapy first. So that is problem # 1, insurance may deny use of first line immunotherapy in a patient with ALK (+) NSCLC. I am not aware of a head to head comp...