Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach a patient with DPD deficiency that experiences severe toxicity on 5-FU despite dose reduction in the setting of metastatic colorectal cancer?
This depends on the mutation. Most patients heterozygous for DPYD mutations can be treated with dose-reduced 5-FU or capecitabine. Guidelines from CPIC (Clinical Pharmacogenomics Implementation Consortium) give recommended dose reductions for specific genotypes - a 50% dose reduction is appropriate ...
Is Ki-67 expression routinely performed on ER+ breast cancer patients and do you find that information useful for making treatment decisions?
Our institution's pathologists do not routinely test for or report Ki-67 expression in any subtype of breast cancer; while I sometimes see this value on path reports from outside institutions in patients referred for consultation or second opinion, I am hesitant to use it to determine treatment reco...
What would be your choice of endocrine therapy for a patient with HR+ early stage second breast primary after completing 5 years of adjuvant AI?
There are no studies to provide guidance in this situation as far as I am aware as most adjuvant studies excluded patients with prior history of breast cancer. Given that the second primary breast cancer was discovered 2 years after completion of adjuvant aromatase inhibitor, it probably developed a...
How do you approach your choice of systemic therapy for relapsed/metastatic H&N cancer (failed definitive concurrent chemoRT) not amenable to further locoregional therapies?
If patients fail CRT with a platinum-based regimen within 6 month of the completion of treatment, I generally give them I/O therapy. If > 6 months, the SOC right now is to treat with a platinum based regimen, i.e. EXTREME regimen or a platinum doublet. I will often give a modified version of EXTREME...
Do you use cabozantinib preferentially over other TKIs in mRCC patients who have progressed on immunotherapy with primary metastatic burden being bony disease?
Cabozantinib sounds a very good option in that scenario extrapolated from data from the METEOR (but differences in prior therapy) & CABOSUN trials (in different line of therapy). If a patient can tolerate it, it is a very reasonable option.Other VEGF TKIs (e.g. axitinib, sunitinib, pazopanib), lenva...
In which clinical situations, if any, would you use imiquimod for treatment of breast cancer skin metastases?
Imiquimod is synthetic toll-like receptor (TLR)7 agonist that has immunostimulatory effects when applied topically. Topical application can enhance clearance of human papillomavirus (HPV)-​related genital warts, and might lower cancers associated with HPV, and is approved for that purpose. It has ...
How would you treat frontline metastatic ER+HER2- breast cancer with activating PI3K mutations?
Outside of a clinical trial, I would still treat patients with HR+/HER2-, PIK3CA mutant, metastatic breast cancer with hormone therapy + CDK 4/6 inhibitor. At this moment, we are still awaiting approval of alpelisib. In the phase 3 SOLAR-1 trial, 341 patients with PIK3CA mutant tumors were randomize...
Do you send multiple Oncotype testing for each sample in a multifocal or multicentric breast cancer?
I would consider this only if our pathologists report significant differences in the appearance or histologic grade hormone receptor expression of different foci; even then, my inclination (in most cases) would be to have them submit only the focus with the highest grade or lowest ER/PR expression, ...
What is your preferred approach for stage III NSCLC with single station N2 disease amenable to lobectomy?
The question of how to handle operable IIIA patients with limited N2 disease has always been controversial, and the new PACIFIC data just makes it more complicated.At some level, it becomes a duel of unplanned subset analysis and a bit of apples to oranges, which is always to be taken with a grain o...
Do you utilize consolidative radiation for metastatic NSCLC lung cancer patients on maintenance immunotherapy?
Yes but please refer these patients for NRG-LU002 study which is directly addressing this important question.