Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
With recent measles outbreaks occurring in the US, would you consider offering multiple myeloma patients s/p ASCT on maintenance treatment vaccination, or an alternate means of immunity?
Measles is on the rise and protection is appealing. The current guidelines for adult immunizations are not clear what patients with monoclonal gammopathy (MGUS), smoldering myeloma (SMM), or multiple myeloma should do. Are they all immunocompromised? Are they all immunocompromised to the same amount...
After progression on osimertinib, do you recommend overlapping TKI with 2nd line chemotherapy to avoid accelerated disease progression?
I do not continue the EGFR TKI in patients once clear evidence of clinical and radiologic progression makes me recommend a switch from an EGFR TKI to chemotherapy. This approach is considered due to reports regarding the potential tumor flare phenomena noted upon discontinuation of EGFR TKIs. There ...
How would you manage an elderly patient with a history of stage I CLL and newly diagnosed metastatic ER+/HER2+ breast cancer?
The focus would be on the diagnosis which seems most likely to be life-limiting and/or a source of morbidity. Although there aren't many details here regarding the metastatic ER+ HER2+ breast cancer (e.g. where are the mets? Bone? Liver? Are there symptoms?) one presumes that this is more life-limit...
How do you approach adjuvant chemotherapy in early stage ER+ breast cancer who developed pneumonitis on ddAC?
Neulasta with ddAC can cause an interstitial pneumonia or reaction like pneumonitis. If she was node positive, younger and you think rechallenging her is reasonable (the pneumonitis was grade 1-2 and resolved quickly on steroids) then you could try to do the remaining AC q3wk without Neulasta to see...
How would you treat a triple negative large (~ 6 cm) cancer in a woman in her second trimester of pregnancy?
There is data for the safety of anthracyclines in pregnant women. I would treat her with AC every three weeks for up to 4 cycles with close monitoring by a high risk obstetrician. There is also data for the safety of paclitaxel. I would treat her with chemotherapy till delivery and then proceed with...
In the absence of specific driver mutations, are you routinely offering combination chemotherapy + immunotherapy first-line for metastatic squamous cell carcinoma of the lung in patients with autoimmune disease, but not currently on immunosuppression?
It depends on the nature of their autoimmune disease. If a patient has antiphospholipid antibody syndrome, it may be quite dangerous. If isolated antibody without clinical syndrome, IO may or may not unmask APLS. That said, metastatic squamous lung cancer is incurable and the only chance for durable...
Do you consider MET amplification in your first-line treatment decisions for patients with metastatic NSCLC?
Not at present and nothing is FDA approved or NCCN guidelines. Second line or later yes, especially on a trial
With the approval of frontline pembrolizumab monotherapy for advanced NSCLC with PD-L1 of 1% or above, how do you select who gets Chemo-IO versus pembro monotherapy if PD-L1 between 1-49%?
Most patients with PDL1 1-49% should continue to be offered chemotherapy + IO and not pembrolizumab alone.
Do you implement an age cut-off for determining use of adjuvant chemotherapy for Stage III ER+ PR+ breast CA?
No. But, I carefully assess functional age based on patient's daily activity level. If the patient has poor functional status, and has a high risk of cancer recurrence, I use clinical judgement to determine the value of adjuvant chemotherapy and discuss the pros/cons with the patient.
Do the results of S0226 change your endocrine therapy of choice in denovo metastatic hormone positive breast cancer?
S0226 compared anastrozole to anastrozole plus fulvestrant loading dose in first-line treatment of metastatic ER-Positive Breast Cancer. The combination arm was more effective than anastrozole alone, with a significant improvement in PFS and OS. This concept of complete ER blockade has been an attra...