Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach metastatic adenocarcinoma of the lung with ROS1 rearrangement by FISH and EGFR mutation by NGS?
It would be exceedingly uncommon to see a patient with lung adenocarcinoma that harbors a ROS1 fusion and activating EGFR mutation concomitantly. It is generally thought that driver mutations such as EGFR, ALK, ROS1, BRAF, RET, MET, HER-2, and KRAS are mutually exclusive. Having said that, there are...
What would be your first line treatment option for a symptomatic patient with grade 3 well differentiated GI neuroendocrine tumor?
This would be a somewhat unusual scenario in small bowel NETs as they are uncommonly grade 3 (G3). That said, we and others, have increasingly been seeing well differentiated G3 NETs of small bowel origin, usually late in the disease course and in repeat biopsies. Most WD G3 NETs are of pancreatic o...
How does the management of nasopharyngeal cancer in kids/young adults differ from adult patients?
The approach for managing pediatric patients with NPC has generally followed the recently published COG trial, at least in the United States. This approach uses induction chemotherapy with CDDP/5FU, followed by chemoradiation for the higher risk patients. Lower risk patients—Stage I/IIa or T2N0—can ...
How would you approach a postmenopausal female with TNBC (with LN involvement) and CKD Stage 5?
As with all patients with comorbidities, I start with multidisciplinary involvement and a consideration of performance status and life expectancy. I would speak to the nephrologist, and whoever is handling the multiple myeloma, about the prognosis of each of those. If the performance status is good ...
How would you approach a patient with a HER2+ locoregional recurrence who did not receive prior systemic therapy?
For a patient with an isolated, small in-breast recurrence, I would consider this a marker of a higher risk of distant recurrence and would give systemic adjuvant therapy, but would limit treatment to weekly paclitaxel and trastuzumab, since this is less toxic than the more aggressive regimens and h...
For a patient with stage 4 lung cancer PDL1 TPS > 50% and long term history of myasthenia gravis stable on mycophenolate, would you ever consider pembrolizumab or would this be absolute contraindication?
Myasthenia gravis is one of the autoimmune conditions that I would consider a contraindication for immunotherapy. If myasthenia flares, the consequences are life-threatening, and can become extremely difficult to treat. I have personally experienced a patient who developed de novo myasthenia on immu...
In a patient with pN1 penile squamous cell carcinoma s/p inguinal lymph node dissection, would you offer adjuvant TIP vs adjuvant chemoRT vs surveillance?
With no high risk features (i.e. pN1 disease is <= 2 unilateral inguinal lymph nodes involved with no extracapsular extension), the best evidence for any treatment would be for adjuvant chemoradiotherapy which would come from an extrapolation of a GOG study on vulvar cancer. As reference, NCCN Guide...
What is your preferred treatment dose and schedule for capecitabine for patients with metastatic breast cancer?
In the literature, the 1000 mg/m2 BID for 14 days on/7 days off has similar efficacy (J Clin Oncol. 2005) and lower toxicity (Breast Cancer Res Treat. 2016) than 1250 mg/m2. Because of variations in our group, one of our clinical pharmacists reviewed all of our patients based on different dosing sch...
Do you consider adjuvant chemotherapy in a patient who has received ddMVAC preoperatively and had pT3pN2 disease at time of surgery?
No. There is no high level evidence of doing that. I would strongly favor clinical trial, e.g. AMBASSADOR is accruing (or active surveillance if no trial available).
How would you approach the treatment of early stage rectal adenocarcinoma in patients with confirmed Lynch Syndrome?
If this patient has T3+ or N+ disease, I would favor "TNT" - total neoadjuvant therapy with FOLFOX where you can carefully monitor for response (or lack of response). Lynch Syndrome does not predict for lack of response with oxaliplatin regimens. See for example Yacoub et al., PMID 23730227. With ra...