Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach elderly patients with stage III NSCLC who have a reasonable performance status?
Prior to answering this question, I should be clear that I have no additional geriatric oncology training or expertise other than someone who has treated lung cancer patients for more than 25 years. Generally I approach elderly patients in the same way I approach the younger with the caveat that I f...
How would you manage a patient with minimal residual disease (<1% of CD25 positive cells) six months after completing therapy with 2-CDA for Hairy Cell Leukemia?
This is a challenging question. Patients with HCL who have MRD after treatment with cladribine or pentostatin have shorter remissions than those who have pathologic remissions. Several studies have shown eradication of MRD with subsequent treatment with rituximab. Thus, utilization of rituximab afte...
Would you change treatment for denovo stage IV breast cancer Her 2 positive, ER positive in remission now with isolated brain metastasis?
I would not change systemic treatment for such a patient if they have stable disease outside the brain. The intracranial disease should be treated with SRS or WBRT or surgery, as the case may be. With the various anti Her-2 treatment options in this setting, namely trastuzumab, pertuzumab, T-DM1 and...
At what ANC do you hold weekly Taxol for adjuvant therapy of Her2 positive breast cancer?
it depends a little on risk of bleeding and disease, but in general 100k I dose reduce. Hold at 80k.
Do you continue ovarian suppression for pre-menopausal women with HR+ breast cancer after progression on ovarian suppression + AI + CDK4/6 inhibitor (i.e. when fulvestrant is the appropriate next line of therapy)?
I do. Fulvestrant is technically an anti-estrogen receptor blocker that should work in pre or postmenopausal women. However, data in premenopausal women is limited. There would be at the least, some additional estrogen lowering effect and no harm from ovarian suppression. Therefore I would continue ...
How would you treat a patient with a known history of ER/PR 90% and HER2 negative who develops skeletal metastatic disease on adjuvant endocrine therapy but now ER is only 2% and is PR and HER2 negative?
While I sometimes question results of receptors obtained from decalcified bone biopsies, this patient's clinical history (high risk by Mammoprint despite strongly positive hormone receptors, early disease recurrence) suggests that the behavior of her cancer is being determined by a hormone therapy-r...
Have you changed your steroid pre-medication regimens when treating with chemo-immunotherapy combinations for metastatic NSCLC vs chemotherapy alone?
I have not changed the recommended premedications for chemotherapy when giving chemotherapy combined with checkpoint inhibitors as the trials did not do this. Also there does not seem to be a difference between nab-paclitaxel and taxol in trials in squamous cancers.
What is the clinical utility of the Combined Positive Score (CPS) for PDL-1 expression when considering pembrolizumab for gastric cancer?
From multiple studies, it is very clear that higher staining for PDL-1 on tumors and immune cells (combined expression, resulting in the CPS (combined positive score)) is correlated with increased Response Rate, PFS and clinical benefit of anti-PD1 drugs. Pembrolizumab is approved for gastric cancer...
How would you treat low grade follicular lymphoma with diffuse epidural involvement? Would you give intratheracal or high dose systemic methotrexate in addition to systemic chemoimmunotherapy?
This is a rare presentation of follicular lymphoma especially if its primary epidural lymphoma without presentation outside the epidural space. This entity was traditionally treated with combined chemotherapy and radiotherapy and associated with a poor prognosis of less than a year. I would conside...
What is your preferred regimen for metastatic bladder adenocarcinoma?
Clinical trials, e.g. ICONIC (PI: Dr. Andrea Apolo) would be very interesting if slots are available. Outside trials, would consider FOLFOX (or FOLFIRI if neuropathy is an issue) as a 'colorectal-like' regimen (GI Med Onc can help manage regimen based on their experience). Dr. Siefker-Radtke had a t...