Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer the PACIFIC protocol to a patient with stage III lung cancer with performance status 2-3?
The PACIFIC trial did not evaluate this regimen in patients with performance status 2-3. Durvalumab dosing does not change based on toxicity. I do not use this regimen for patients with PS 2-3 without supporting data at this time.
Should breast cancer patients with never-treated latent TB and for whom chemotherapy is indicated be treated for latent TB during chemotherapy?
Interestingly latent tb reactivation while on cyclic combination Chemotherapy is quite rare even in endemic countries like India, including among patients treated for leukemia. This could be due to cyclic nature of immune suppression rather than chronic immune suppression which is required for tb re...
Should upfront neck dissection in head and neck squamous cell carcinoma obviate the need for chemo in a T1N2 oropharyngeal cancer with no ECE?
While I do not advocate a neck dissection to avoid chemotherapy, when these patients come to our institution already having a ND performed, if there is no ENE and the primary tumor is small, I think RT alone is reasonable.
How would you treat a young patient with good performance status who has de novo metastatic HR+ Her2+ inflammatory breast cancer with asymptomatic leptomeningeal and CNS parenchymal disease?
If her CNS parenchymal disease is low burden and amenable to SRS I would do that first. Then place an Ommaya followed by initiation of TPH plus ovarian suppression. Finally, would begin concurrent weekly IT trastuzumab 20mg with regular monitoring of CSF for clearance of cells plus follow up brain M...
How do you counsel patients who inquire about response rates in metastatic breast cancer?
I typically explain what response rate, response duration and progression free survival means and make sure that patients are aware that the outcome of interest reported in clinical trial represents a mean value and that patients enrolled in the study had a range of responses, some were better than ...
How do you manage pneumonitis in patients with Stage III NSCLC receiving durvalumab?
Pneumonitis is a concern following chemoradiation (CRT) alone, and the addition of durvalumab leads to increased caution. Patients on the durvalumab arm in the PACIFIC trial, had some increase in pulmonary adverse events. Any-grade cough (35.4%) and pneumonitis or radiation pneumonitis (33.9%) were ...
Does consolidation durvalumab increase the risk of pneumonitis in Stage III NSCLC?
Given the heterogeneity of pneumonitis presentation, the presence of pre-checkpoint inhibitor chest/mediastinal irradiation (by definition in this trial), and the other risk factors often seen in this population (COPD/emphysema, current/past smoking history), it is a real challenge to decipher pulmo...
How do you advise patients looking for 2nd opinions while on standard-of-care, first line treatment for metastatic ER+HER2- BC(i.e. a CDK4/6 inhibitor + aromatase inhibitor) to bolster requests for chemotherapy when non indicated?
This scenario comes up very often in clinical practice. There are many unanswered questions regarding the optimal treatment strategy in this setting. Trials evaluating the optimal treatment sequence and biomarkers driven therapies are urgently needed. In general, resistance to hormonal therapy is ra...
Do you make diagnostic lumbar puncture part of routine work up for newly diagnosed AML if patient is asymptomatic?
Unlike acute lymphoblastic leukemia (ALL), central nervous system (CNS) involvement by acute myeloid leukemia (AML) occurs in less than 5% of patients at the time of diagnosis. Therefore, routine lumbar puncture is not recommended for asymptomatic patients. Certain clinical and biological features h...
When do you consider total neoadjuvant therapy (chemotherapy and chemoradiation) for rectal cancer?
My practice, and that of my group, has moved more towards a TNT model for stage II and III patients, though I think we are all looking for the PROSPECT data to be finalized. NCCN has adopted TNT as a possible consideration, and other groups are considering this more and more (Cercek et al, Jama Onco...