Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a locally advanced TNBC and a malignant appearing renal mass suspicious for a synchronous renal cell carcinoma?
The answer to this question (in my view) depends largely on the extent of the renal cell carcinoma. Historically, renal cell carcinoma is still managed largely by up front surgical resection. If the suspected second primary were small and the oncologist felt like close observation was possible, one ...
What is the role (if any) for Rituximab in a patient with CD20+, Philadelphia chromosome positive ALL?
There are no good randomized data in PH+ disease, but the incorporation of rituximab for CD20+ and PH+ ALL has been standard practice on MD Anderson trials of HyperCVAD+TKI. The challenge has been more on the insurance side - but our approach is to include it if approved.
In a germline BRCA2 positive pt with NSCLC after chemoIO frontline and taxotere as a second line, would you consider PARP inhibitors?
This is a challenging situation and one I have encountered in clinic. The data for PARP inhibitors in NSCLC is limited. There have been limited trials for this specific population including NSCLC so I have extrapolated from the breast/ovarian experience. For instance, there was a phase II clinical ...
Do you consider using capecitabine and irinotecan (XELIRI) instead of FOLFIRI for first line metastatic colorectal cancer?
There are no data to suggest that CAPIRI is more effective than FOLFIRI. However, the former is a much more toxic regimen, primarily because diarrhea is a significant, overlapping toxicity with capecitabine and irinotecan (BICC-C trial, JCO 2007). Consequently, I don't use CAPIRI.
Do you consider tumor mutation burden as a possible biomarker for response to immune checkpoint therapy in the second line setting for cervical cancer?
According to NCCN guidelines, pembrolizumab could be used as a second line therapy for tumors that are PDL1 positive, can be categorized as MSI-high (high microsatellite instability), or are deficiency in mismatch repair (Le DT, et al. Mismatch repair deficiency predicts response of solid tumors to ...
What is the threshold for negative surgical margins in multifocal microinvasive carcinoma of the breast?
I think it is reasonable to forego re-excision in this case if the margin is focally (i.e. < 4 mm) less than 0.1 mm, and the patient proceeds with appropriate adjuvant therapies. Re-excision could be considered if the span of DCIS close to the margin is extensive. The panel who delivered the DCIS ma...
Would you test for ESR1 mutation prior to deciding on AI or fulvestrant for metastatic breast cancer?
As with so many things in breast cancer, the answer for me is that it depends.The argument against testing is that the presence of ER-mutations before treatment with an aromatase inhibitor is low (<10% and in some series <5%, Cancer Discov. 2017, Mol Oncol. 2018, for example), and while PFS with AI ...
Would you give adjuvant endocrine therapy for a patient with T1a luminal A breast cancer?
If the patient elects to undergo breast conservation then you can offer endocrine therapy with the same intent as ER+ DCIS. It is more to reduce a future second cancer rather than to significantly reduce the risk of metastatic recurrence.
How do you approach nodal coverage in PORT for NSCLC with involved station 8?
My recommendation is to review pre-op image and discuss with the surgeon who did the operation. Station 8 is not routinely sampled or dissected for NSCLC. I don't recommend to cover GEJ routinely due to toxicity.
What changes, if any, would you make to a patient’s endocrine therapy for a patient with DCIS on tamoxifen for risk reduction who develops a new lesion (LCIS) while on tamoxifen?
Assuming post menopausal I would switch to anastrozole. There are published data on anastrozole for chemoprevention. Although no head to head comparison with tamoxifen A.I.'s superior in every other breast cancer scenario. (second and first line metastatic and adjuvant) Thus nothing to be lost in s...