Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Aside from MET exon 14 skip mutations, are there other targetable MET mutations or fusions that you would consider for TKI therapy?
MET exon 14 skipping mutations are a heterogeneous group of mutations that result in the absence of a juxtamembrane domain leading to constitutive activity of the MET receptor. Over 100 genetic variants have been described. In addition to MET exon 14 skipping mutations, MET amplification has also be...
For patients with EGFR-mutant NSCLC who progress on osimertinib, do you repeat tumor molecular profiling?
I do favor repeating a tumor biopsy in patients that progress on osimertinib. If I send cfDNA that would be concurrently not instead of tumor tissue. The mechanisms of resistance to osimertinib are many including the emergence of C797S mutation, MET amplification, HER2 amplification, BRAF 600E mutat...
What non-taxane chemotherapy can you partner with trastuzumab/pertuzumab for HER2+ breast CA if neuropathy either at baseline or with treatment becomes prohibitive?
For less neuropathic agents there are safety/efficacy data from the PHEREXA trial combining capecitabine with pertuzumab and trastuzumab (Urruticoechea et al JCO 2018). We also presented data on using gemcitabine with pertuzumab and trastuzumab in a small phase 1/2. (Soliman et al JCO 2016). The dat...
For metastatic pancreatic cancer, is there a role for maintenance chemotherapy if patient has stable disease at the end of 12 cycles of dose reduced modified FOLFIRINOX?
Although the original FOLFIRINOX data (Conroy, NEJM, 2011) evaluated efficacy of a six-month course of treatment in patients with metastatic pancreatic cancer, few of us would feel comfortable discontinuing chemotherapy entirely for these patients at the end of a six month period. In the absence of ...
In a patient with ILD and metastatic NSCLC with positive PD-L1, would you give chemo/pembrolizumab, chemotherapy alone, or pembrolizumab alone?
We always discuss the risks and benefits of treatment to every patient; however, patients still rely upon our best judgment to guide decisions. I would not recommend a PD-1 or PD-L1 inhibitor to a patient with known interstitial lung disease. These patients were excluded from the Keynote, Checkmate,...
What second line therapy do you use for metastatic gastroenterohepatic neuroendocrine carcinoma (G3 NEC) with progression after platinum based therapy?
I completely agree that convincing evidence is lacking. We tend to lean on 5-FU and irinotecan based regimens, based on the FFCD-GTE data and the case report-level data with FOLFIRINOX (PMID 25662891). While there are also retrospective data with TMZ-based regimens, published data are not as clear o...
How would you approach a metastatic ERBB2 amplified gallbladder carcinoma?
You have hit on a clinical scenario for which we have clues about helpful therapy, but no definitive data to guide us. For a HER-2 amplified gallbladder or biliary cancer, I do think the data support targeting this pathway at some point in the patient’s care. As you point out, the best data are from...
Do you recommend neoadjuvant radiation or chemoradiation for patients with T1-2 N0 adenocarcinoma of the anal canal prior to APR?
For the most part, anal adenocarcinoma is treated like rectal adenocarcinoma. Therefore, as the question is written, i.e. the patient will be getting an APR, I don't think there is enough data of a benefit for treating a T1-2 N0 adenocarcinoma with chemoradiation to justify the toxicity. However, i...
What chemotherapy regimen do you recommend with radiation therapy for cervical esophageal squamous cell carcinoma?
I would use weekly carboplatin/paclitaxel in this setting. Fluoropyrimidine + platinum is reasonable but will likely be more toxic, and I'm not aware of any data indicating that it's a more effective regimen.
Do you consider initiating systemic therapy for patients with NSCLC who develop oligometastatic disease and have all known sites of disease treated with SBRT?
This is a very intriguing and challenging question and addresses a not so uncommon clinical scenario when patients present with one or just a few sites of recurrent disease after delivery of what was considered to be definitive therapy. In such contexts many times it appears appealing and appropriat...