Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What systemic therapy would you offer to a postmenopausal patient with an unresectable local recurrence of HER2+/ER weakly + IDC?
For local recurrences, in general I think about 4 situations based on whether it is resectable or not and whether it is during or soon after adjuvant therapy or not. In this case, we have an unresectable local recurrence during adjuvant therapy within a year after surgery, since it is during adjuvan...
Would you consider perioperative immunotherapy for a patient with locally advanced, resectable gastric cancer but not a candidate for chemotherapy?
Some aspects of the management in this situation are influenced by the surgical candidacy. If this patient is not a candidate for chemotherapy it would be critical to have a multidisciplinary assessment for surgical candidacy. Unfit for chemo but fit for surgery is a relatively uncommon clinical sit...
How do you treat recurrent dedifferentiated liposarcoma after initial complete resection if the recurrence is multifocal but surgically resectable?
How do you use neratinib in HR+ HER2+ patients in the adjuvant setting if patients got adjuvant T-DM1 for residual disease after neoadjuvant therapy?
I do not routinely apply neratinib. I base the decision on my best estimate of two factors: The obvious issues with neratinib toxicity The residual risk that the patient has after TDM1. Not all residual disease patients are equal. I would approach a patient with a minimal response to neoadjuvant th...
What is your preferred TKI and dosing for AYAs or adult patients with Ph+ ALL?
We typically follow the MD Anderson updated approach of adding dasatinib 100mg daily for first 2 weeks in cycle 1 and then 70mg daily starting cycle 2 (Cancer 2015; 121:4158).How long to continue? That’s a tough one with essentially no mature data. The COG study continued for only 2 years, though da...
Is there a role for a PDL-1 inhibitor in patients with chemo-refractory metastatic esophageal adenocarcinoma with PDL negative, MSI stable disease?
For metastatic large cell neuroendocrine carcinoma of lung, would you treat as small cell with platinum/etoposide/atezolizumab or would you treat as NSCLC and use platinum doublet/pembrolizumab?
Can consider NGS and treat like SCLC if there is Rb/p53 mutation pattern and NSCLC if STK11/KEAP1 pattern (later prob Immunotherapy resistant?) https://www.esmo.org/Conferences/Past-Conferences/ESMO-2017-Congress/News-Articles/Improved-Survival-Demonstrated-with-NSCLC-chemotherapy-in-Pulmonary-Lar...
How would you approach primary CNS lymphoma in an elderly patient over 80 years old?
Patients >70-75 are poorly represented in trials and retrospective studies, and are in need of novel therapies with minimal toxicity. We know that radiation therapy is associated with increased neurocognitive morbidity in patients >60, but is often the only feasible approach if chemotherapy cannot b...
For patients with metastatic radioctive iodine refractory papillary thyroid carcinoma that is BRAF V600E mutant and rapidly progressive, would you consider dabrafenib/trametinib combo instead of lenvantinib or sorafenib first line?
This is an ongoing debate among endocrine and head and neck oncologists; we have phase III data of lenvantinib which is pretty strong, although with tolerance issues when used at full approved doses (24 mg/day, SELECT trial). On the other hand, there is only phase 2 data for BRAF positive DTC using ...
What is the most appropriate adjuvant chemotherapy regimen for pre-menopausal, pT1bN0, TNBC?
In my opinion for T1bN0 TNBC tumors TCx4 is sufficient. In the ABC trials the absolute difference in N0 TNBC between the TCx6 and TaxAC arms was only 2.5%. This included larger tumors over 1 cm. A retrospective study in 1151 TNBC T1cN0 patients found a benefit for adjuvant chemotherapy in T1c patien...