Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach frontline treatment of a patient with metastatic non-squamous NSCLC with ERBB2 amplification and PD-L1 > 50%?
This interesting case brings up how to separate in our work fact from fiction. We are presented with a case of a patient with metastatic non-squamous non-small cell lung cancer with a PD-L1 TPS score of 55% and ERBB2 amplification by Foundation One testing.What is the right approach? Standard chemo/...
How do you approach G-CSF use when offering neoadjuvant chemoRT for lower extremity soft-tissue sarcoma?
We don't use concurrent chemo and XRT so it is not an issue for us. I suppose the detrimental effect of XRT on cycling progenitors would depend on the field that is being irradiated. Typical extremity STS may not pose a big risk, but pelvis would.
How would you manage a patient with no driver mutation, PD-L1 <50%, with systemic relapse of lung adenocarcinoma within a year after resection and completion of adjuvant platinum based chemotherapy?
I don’t think the addition of Bev as seen in the IMPOWER trial added much beyond the activity of the triplet therapy seen in KN 189, and if the patient retains a decent PS on progression, you can then use docetaxel/ramucirumab.
Do you consider discontinuing brentuximab in stage III-IV classical Hodgkin lymphoma patients on AVD+brentuximab who have a good response to 2 cycles?
Now that the 4 year progression free survival results are available (Bartlett, 2019 ASH abstracts, #4026: 4-y PFS A-AVD 82%, ABVD 75%), the evidence for superiority of A-AVD is clear. This better outcome with A-AVD was achieved when the brentuximab was kept included through all 6 cycles of chemother...
In a patient with M0CRPC with PSA doubling time < 6 months, will you wait until the absolute PSA value is >2, or is PSADT alone sufficient to start an AR targeted agent?
The SPARTAN trial required patients to have evidence of PSA progression per Prostate Cancer Working Group 2 (PCWG2) criteria at the time of enrollment. Per PCWG2 criteria, the PSA must be ≥25% and ≥2 ng/ml above the nadir, and it must be confirmed to be rising ≥3 weeks later. Similar eligibility cri...
Would you consider checkpoint inhibitor therapy alone in a patient with metastatic NSCLC with PDL-1 < 1% who is otherwise refusing chemotherapy?
I would not personally recommend a checkpoint inhibitor in the first line setting of a PDL1 negative metastatic NSCLC. I think genomic analysis would help guide that decision as well. For example, the presence of an STK11 mutation would make me even more hesitant to recommend a single agent checkpoi...
How do you determine whether to choose a non-anthracycline neoadjuvant chemotherapy regimen in a fit patient with TNBC?
Optimal neoadjuvant chemotherapy (NAC) regimen for TNBC has not been established and treatment regimens are usually mirrored from adjuvant trials. When choosing neoadjuvant chemotherapy regimen, the goal should be to achieve pathological complete response (pCR), since patients who do not achieve a p...
What is your preferred chemotherapy regimen for patients with peripheral neuropathy and high risk HR+/HER2- breast cancer?
Taxanes tend to improve outcome for all subtypes of breast cancer; several trials including BCIRG 001, CALGB-9344, and NSABP B-27 and B-28 have shown taxanes to be an important component of adjuvant chemotherapy regimens for patients with high risk cancers, including Hormone receptor positive, node-...
What is the protocol for stopping TKI used in RCC prior to a surgery?
It depends on the half life of the TKI, but generally I stop 4-5 half lives prior to any invasive procedure from dental work to a major surgery. The bigger issue is when to restart afterwards, and I usually wait until surgical wounds are 90% or more healed. This might depend on the disease status of...
For metastatic thymic carcinoma or thymoma, after 6 cycles of chemotherapy (ie cisplatin, cyclophosphamide, doxorubicin) with good a response, what if any maintenance regimen would you consider?
I would not recommend any maintenance therapy for a malignant thymoma after induction chemotherapy. The NCCN guidelines do not provide a recommendation for the number of cycles in the induction setting, but typically 4-6 cycles are given. However, patients with thymomas can live many years, and I de...