Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does isolated del(5q) have the same prognostic implications for post-PV secondary myelofibrosis as it does in MDS?
Karyotypic abnormalities are rare in PV and ET. Abnormalities in myelofibrosis (MF) that are associated with an inferior prognosis are: 20q-, 13q-, +9, chromosome 1 translocation/duplication, -Y or sex chromosome abnormality other than –Y. There are few reports of del5q in MPN in general and not eno...
How do you manage a breast cancer patient with discordance in hormone receptor status with IHC and Oncotype?
Given the therapeutic window of endocrine therapy, and evidence of efficacy at even low ER expression (but not no expression!), the bar is set low for use of ET. IHC staining is the gold standard and I treat accordingly, so a tumor that is positive on staining for ER but negative on the single RNA b...
How would you approach adjuvant therapy for low-risk stage III colon cancer (T2N1) in an elderly patient with a good PS?
Patients with stage III colon cancer should receive adjuvant therapy to reduce recurrence risk. FOLFOX adjuvant treatment should reduce relative recurrence risk by about 1/3 (e.g from 35% to 25%). Based on the IDEA collaboration, 3 months of treatment is approximately equal to 6 months of adjuvant t...
How would you approach a locally recurrent, unresectable (due to COPD) NSCLC that is ROS1 positive?
It depends on extent of disease, pattern of recurrence. Is this a recurrence post resection? Did the patient receive adjuvant chemotherapy previously? Is it limited to mediastinum? If the patient qualifies for chemotherapy and radiation i would consider it. If he/she do not qualify due to extent of ...
Would you consider 160 mg of Osimertinib as opposed to 80 mg for adenocarcinoma lung with leptomeningeal metastasis?
I have tried it in 1 patient but it did not work, unfortunately. But there is data to support use 80mg dose as well as 160mg dose. There is an abstract from 2017 ASCO with 160mg dose: BLOOM study abstract or https://clinicaltrials.gov/ct2/show/NCT02228369This is an article with 80mg dose: Standard-d...
What would be your next line of treatment for NSCLC adenocarcinoma that has recurred after chemoradiation with cis/etoposide?
In this setting, it would depend upon the timing from completion of definitive chemoradiation and relapse/progression. In the absence of more definitive data, I take my cue from what most "first line" clinical trials have used for their eligibility criteria - patients are candidates (typically) if t...
How would you approach risk-stratification/staging of a extra-gonadal germ cell tumor with both mediastinal and retroperitoneal lymphadenopathy?
Actually there is zero chance a primary mediastinal germ cell tumor would ever have retrograde adenopathy to the RPLN's. Thus this is a primary retroperitoneal germ cell tumor. Assuming no non-pulm visceral mets and markers at good risk level, would treat with BEP x 3. You did not mention pathology,...
Would you consider neoadjuvant endocrine therapy in a postmenopausal patient with ER + locally advanced breast cancer with nodal disease who wants to avoid chemotherapy?
While neoadjuvant endocrine therapy should not be presented to patients as a standard-of-care, it may be an appropriate option for certain carefully counseled patients. I would consider it reasonable in a patient for whom chemotherapy would NOT be an option (e.g. too frail, too unhealthy, or patient...
What is the role of Braftovi (encorafenib) and Mektovi (binimetinib) in combination for unresectable or metastatic melanoma?
This is a very timely question with the FDA approval of the encorafenib/binimetinib regimen. There are no randomized head-to-head trials comparing BRAF/MEK inhibitors so there are no clear data to guide which regimen is the most effective. The COLUMBUS trial reported the longest OS, PFS with the enc...
Do you ever recommend PORT or chemoRT rather than chemotherapy alone for NSCLC with adverse features other than positive margins or N2 disease?
Despite the numerous limitations of the PORT meta-analysis, and subsequent non-randomized studies of postoperative RT in NSCLC, one message seems clear (at least to me)- radiation therapy can cause harm. In patients with resected lung cancer (who often have many co-morbidities), prudence seems a wis...