Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any role for neoadjuvant therapy in urothelial Tis refractory to BCG therapy?
No clear role of systemic chemotherapy prior to radical cystectomy. The latter alone is the SOC in this setting; clinical trials should be certainly considered especially in patients who either refuse or can’t tolerate radical cystectomy for BCG unresponsive high risk NMIBC.
For patients with HER2+ breast cancer with a resectable HER2+ local relapse within 12 months of completion of standard adjuvant therapy including 1 year of trastuzumab, what adjuvant therapy would you recommend?
This is an interesting question as it implies likely primary resistance to trastuzumab. First, it depends upon the type of recurrence the patient experienced (ipsilateral, contralateral, chest wall recurrence post-mastectomy or axillary recurrence). Second it depends on the hormone receptor status o...
How would you treat a isolated, high grade neuroendocrine carcinoma of the neck with no obvious primary or systemic disease?
I would treat with chemo XRT and have found pelvic disease that way and rx edthat way and pt did v well for a long time.
Would you prefer FGFR inhibitor or second line immunotherapy in a patient with metastatic urothelial cancer of the bladder with FGFR mutation?
I would clearly prefer immunotherapy specifically with the use of pembrolizumab. I would measure the PDL1 CPS expression, where the impact is much greater. Phase 3 data clearly shows significantly improved survival compared to chemotherapy or BSC. This is the first positive trial in the second-line ...
What is your preferred systemic therapy for metastatic malignant peripheral nerve sheath tumor with early relapse after adjuvant AIM?
Persons with MPNST and NF-1 do worse than people without NF-1. I am suspicious that MPNST in persons without NF-1 is actually more than one entity but in NF-1 it is all the same entity.I have had some success with pazopanib in persons without NF-1. Also I have seen two persons who responded to the c...
Would you offer WBRT to a patient with ES-SCLC with improving brain mets on immunotherapy?
The answer to this question arises more from the domains of personal opinion and anecdotal experience rather than a strong evidence basis. The study establishing the value of atezolizumab in this setting (N Engl J Med 2018) does not provide data specific to informing a management approach.At my own ...
For a patient with relapsed FLT3 positive AML on HMA and venetoclax, is there ever a role for the addition of midostaurin to the treatment regimen to improve response rate?
Short answer is no. The safety of the combination is unknown and there’s also not an indication for Midostaurin in relapsed AML. The trial that got Midostaurin approved was for combination with 7+3 in newly diagnosed patients. HMA+ venetoclax has better response frontline compared to relapsed/refrac...
Would you deliver SRS/XRT for isolated asymptomatic CNS metastasis before start of immunotherapy for stage IV lung cancer (negative for driver mutation) with high positive PDL1?
Good question. To my knowledge, we still do not have large prospective studies of combination SRS and ICI in NSCLC, but we do have several retrospective studies. Overall, patients with brain metastases from NSCLC treated with ICI seem to do better than we would expect for patients treated with chemo...
Would you risk offering alpelisib or everolimus to a patient with metastatic ER+ HER2- breast CA with Type 1 DM?
In the randomized phase 3 study with alpelisib (Andre, 2019 NEJM) patient with type 1 diabetes or uncontrolled type 2 diabetes were excluded. Nonetheless, the most frequent adverse events of grade 3 or 4 were hyperglycemia (36.6% in the alpelisib–fulvestrant group). Given lack of data and high incid...
How do you decide between carboplatin vs not recommending adjuvant chemotherapy entirely for patients with resected NSCLC with relative or absolute contraindications to cisplatin?
While I am unaware of any study directly addressing this question (in the adjuvant setting), there is clearly a general preference for cisplatin in the curative setting, hence the question. Reworded - is carboplatin SO inferior to cisplatin that you wouldn't give four cycles of a carboplatin regimen...