Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Can 5-FU be substituted for adjuvant capecitabine for a dialysis dependent patient with triple negative breast cancer s/p neoadjuvant chemotherapy followed by mastectomy showing small residual disease?
I would not substitute 5-FU in this situation.Although the CREATE-X trial showed a survival benefit for adjuvant capecitabine in women who do not achieve pCR with neoadjuvant chemotherapy in a subset analysis of women with triple negative breast cancer, there are reasons to be concerned about these ...
What are the clear criteria for unresectability in locally advanced NSCLC patients, other than medical or anatomic?
Unfortunately there is not a clearly defined criteria to answer your question. As you stated much of the debate is centered around what is "resectable N2" disease. Since there is no clear definition of what surgically resectable N2 disease much of these treatment decisions are dependent on individua...
How do you identify immunotherapy-related pneumonitis vs. radiation pneumonitis in a patient status post chemoradiation receiving consolidation immunotherapy?
Unfortunately, it can be quite difficult to discern the two. Radiation pneumonitis is classically more focal within the treatment field, however, it is absolutely possible to get a more diffuse pneumonitis even with focal RT (albeit uncommon).https://www.ncbi.nlm.nih.gov/pubmed/15256622Immunotherapy...
In otherwise stage III NSCLC patients with a single metastatic site that is treated definitively (radiation or resection) followed by standard of care chemoradiation, would you still consider consolidation immunotherapy?
This is a stage IV lung cancer patient and therefore in such a patient I would first evaluate molecular markers and PD-L1 as I would in any stage IV patient. The marker data will influence my decision about therapy. In the case provided and with the limited information available I am unlikely to co...
In patients witih locally advanced pancreatic cancer, how long would you wait after 1st line induction chemotherapy with FOLFIRINOX before you image for assessment of response and deciding about 2nd-line therapy?
We image with Ca-19-9 every 3 months and consolidate with ablative chemoradiation after a minimum of 4 months of FOLFIRINOX. We do not give second line chemotherapy for locally advanced pancreatic cancer unless patients do not tolerate FOLFIRINOX in spite of dose reductions, or experience progressio...
How would your treat a pregnant woman (2nd trimester) with multifocal HER2+ ER- early stage breast cancer?
Assuming she will continue the pregnancy I would do 4 cycles of AC every 3 weeks then have her deliver the baby as soon as possible. Would then have her finish taxane w herceptin +/-perjeta followed by surgery and additional adjuvant therapy as appropriate.
How do you treat metastatic small cell carcinoma of the bladder cancer refractory to first line cisplatin based therapy?
Clinical trial is ideal; if no trial is available, consider taxane single-agent vs anti-PD(L)1 single-agent, send NGS testing to look for targets. No high-level evidence exists to help select 2L therapy but reasonable to assess TMB and favor pembrolizumab if high TMB as per recent FDA approval. Ther...
For small peripherally located NSCLC, when do consider referral for mediastinal evaluation prior to curative surgery vs proceeding to resection with mediastinal eval at time of surgery?
Although there is variability among the different guidelines (ACCP, ESTS, NCCN) in regards to mediastinal staging, there is consensus that no invasive staging is required for peripheral nodules which are T1A (T1abcN0) given the low prevalence of occult N2 disease. Invasive mediastinal staging should...
Why are hypomethylating agents as single agents not approved yet by FDA for treatment of AML (technically off-label)?
DNA hypo methylation gets agents are not approved as single agents for treatment of AML as Phase 3 studies with both azacitidine and decitabine vs treating physician choice of best alternative regimens failed to meet their primary end-point of statistically significant improvement over-all survival ...
What dosing schedule of cladribine do you use for newly diagnosed hairy cell leukemia in need of treatment?
Great question. For patients who meet criteria for treatment and have classic hairy cell leukemia, both the 7-day continuous infusion of cladribine and the 5-day daily dosing seem to have equal efficacy and toxicity. I think either is fine and patient preference can be considered. The 5-day scheme s...