Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
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...