Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For metastatic NSCLC patients with mixed response to pembrolizumab, would you radiate focal progressing lesions and continue pembrolizumab, add in chemotherapy to pembrolizumab, or discontinue pembrolizumab and move to second line?
These are all reasonable approaches. The better and longer the prior response to pembrolizumab and the more limited the # of progressing sites, the more likely I would be to consider radiating those sites and continuing pembrolizumab alone. I have not yet added chemotherapy to pembrolizumab, but wou...
How would you approach first-line treatment in a young patient with VHL with intermediate/poor risk metastatic clear cell RCC?
Is there currently a role for adding venetoclax to a hypomethylating agent (HMA) after failure of single-agent HMA therapy in MDS?
For patients with MDS who have failed single-agent HMAs, there is an intriguing small retrospective series suggesting that adding on Venetoclax at the time of HMA failure can lead to responses (Ball et al., PMID 32589727). Because of the retrospective nature of this publication and the small numbers...
How do you manage venous thromboembolic events or bleeding events in RCC or HCC patients on anti-angiogenic TKIs?
I generally would not discontinue for a bleeding event for an RCC pts on anti-VEGF therapy. I may hold drug while managing the event if I can control the source of bleeding, but given most options include such an approach would restart cautiously. Similarly for venous thrombotic events I would manag...
How would you approach adjuvant chemotherapy for high grade pleomorphic/dedifferentiated liposarcoma?
These are not impressive results for a retrospective study where I am sure fitter patients are probably selected for therapy. these are very toxic drugs. Can you break down the numbers of pleomorphic in this abstract ( unpublished) to see if we can get a better idea What level of evidence should we ...
Would you perform an oncotype DX in a patient with a 0.5cm ER positive breast cancer with one lymph node positive for macrometastatic disease?
We published data from SEER in May of last year (Massarweh, JCO May 2018) looking at BCSS and OS in 55 thousand women with 0-3 lymph node involvement at 5 years. In patients with low and intermediate RS (up to 30) there is very little difference between node negative and node positive patients in te...
How would you manage DCIS diagnosed in the first trimester of pregnancy?
During the first trimester of pregnancy organogenesis takes place and thus the risk for teratogenic effects of systemic therapies are the greatest. Given that DCIS is a non-invasive form of breast cancer associated with excellent prognosis, my preference would be to wait until at least the second tr...
What is your approach to initial management of patient with clinically palpable axillary disease, histologically proven breast cancer, with no imaging evidence of an occult primary or metastatic disease?
The frequency of TXN+M0 cases has declined with the availability of breast MRI, as many cancers occult on mammography and ultrasound are detected by MRI, but they still occur, and are usually high grade, triple-negative or HER2+. I treat these as I would any patient with node-positive disease, with ...
What would you recommend as a first line systemic therapy for metastatic sarcomatoid carcinoma of the lung without driver mutations?
There is no right answer for this question. The only trials that I am aware of for sarcomatoid carcinoma/carcinosarcoma are in uterine primaries and we don't know if those findings are transferable to other sites. I tend to use carboplatin/paclitaxel/bevacizumab for pulmonary sarcomatoid carcinoma. ...
How do you approach ER, PR weakly positive, HER2 negative breast cancer in the metastatic setting?
Adjuvant studies have suggested benefit to hormone therapy in low ER positive patients, although the absolute benefit may be less. In the metastatic setting, the decision to approach low ER positive, HER2 negative patients with endocrine therapy versus chemotherapy depends on the individual patient ...