Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred radiation sensitizing regimen for cisplatin-ineligible patients with locally advanced unresectable p16+ tonsil SCCa?
If patients are not candidates for cisplatin therapy, I personally would consider a carboplatin-based regimen before considering anything else. If the patient's creatinine clearance is > 30 cc/min, I might give Carboplatin (AUC 6) for a T4 or N3 (Stage III) unresectable tumor. Since p16+ tumors do s...
How would you treat a premenopausal woman with triple positive breast cancer that has not had any therapy with a bilirubin of 10mg/dl due to intrahepatic disease?
Your chemotherapy options are limited but you can give some agents like xeloda with herceptin/perjeta as induction then switch her over to endocrine therapy (ofs + AI) plus herceptin/perjeta like the PERTAIN trial. If you can't give her those agents another option that has pulled some patients out o...
Would you consider using a targeted agent as induction therapy outside of clinical trial for a patient with stage IIIB (N2) who may be a candidate for surgical resection and has a targetable mutation?
It’s a data free zone. If the patient is borderline resectable, it may be a reasonable option to try induction TKI for 1mo and re-image and see if the patient can convert to resectable. But there is limited data here. Post op, I would not do adjuvant TKI, but rather chemo or chemoXRT.
How do you decide between continuing 5FU + Chemo (Oxaliplatin or Irinotecan) + Bevacizumab versus switching to maintenance 5FU + Bevacizumab in the first line setting for metastatic colon cancer?
In general, after 4-6 months of induction chemotherapy, if they experience a favorable response, I would favor maintenance chemotherapy based off several clinical trials which have shown a benefit for a maintenance approach, notably OPTIMOX and CAIRO-3. The continuation of oxaliplatin or irinotecan ...
Do you recommend postoperative radiation therapy for pathologic T1-2N1 small cell carcinoma of the lung?
Post op N1 + small is a very small group of patients. I would not hold your breath waiting for a substantial series and no chance of a prospective randomized trial. In NSCLC, outcomes are WORSE for PORT in N1. An overview of T1-2 patients managed by surgery found no benefit to +TRT to chest; moreove...
Is it safe to deliver SBRT to progressive lung metastases to patients with metastatic RCC receiving concurrent pazopanib?
Generally speaking, yes, it’s safe with some caveats. Pazopanib is a bit of a “dirty” TK inhibitor and so has some VEGF inhibition. That has some implications if you are treating close to hollow viscous like the esophagus, stomach (if on the diaphragm) or trachea. If it’s just open lung, and not cen...
Would you recommend adjuvant radiotherapy with concurrent Ado-trastuzumab emtansine (T-DM1) in your breast cancer patients?
In the Katherine trial (von Minckwitz et al. NEJM 2018) 1486 patients with non-metastatic invasive residual HER2+ breast cancer after preoperative chemotherapy were randomized to 14 cycles of trastuzumab or trastuzumab emtasine (T-DM1), an antibody-drug conjugate of trastuzumab and the cytotoxic age...
How would you modify therapy for a metastatic HER2+ breast CA who develops persistent cardiomyopathy after dual HER2 blockade with trastuzumab + pertuzumab?
The clinical data suggests that dual blockade is not associated with significantly increased cardiomyopathy over trastuzumab based therapy alone. In significant cases holding anti-HER2 therapy for 4-8 weeks can allow the dysfunction to reverse while medical therapy for CHF is optimized. After recove...
How would you manage a patient simultaneously diagnosed with T2N1M0 triple negative breast cancer and T3N2M0 rectal adenocarcinoma?
That is a tough one. I would do the breast surgery first then shortly after do short course radiation to the rectal cancer. Then 1-2 weeks later start 4-6 cycles of dose dense FAC or FEC + Neulasta (to get some 5fu in) followed by the rectal cancer surgery. Then I would do radiation to the breast re...
Would you consider adding IO therapy to 1st-line platinum/etoposide in a patient with metastatic extrapulmonary small cell carcinoma?
The use of platinum based chemotherapy for extra pulmonary small cell is a tradition that has some data to support its use, but the majority of enthusiasm stems from its efficacy in pulmonary small cell. The use of IOs in small cell is now reshaping the field and thus brings this type of question fo...