Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider low dose lenvatinib or dabrafenib/trametinib for rapidly progressive RAI refractory thyroid cancer with BRAF V600E mutation in a patient in whom you are concerned about tolerance of full dose lenvatinib?
I would start with lower doses of Dabrafenib (50 mg BID) and Trametinib (0.5 mg QD) and increase doses as tolerated. I institute Lenvatinib if they fail Dabrafenib and Trametinib. It is not unusual for me to start Lenvatinib at 10 mg daily. But I do not give more 20 mg daily dose.
In patients with metastatic colon cancer responding to treatment with FOLFOX / FOLFIRI with bevacizumab who develop a symptomatic PE, do you continue bevacizumab after treating the PE?
Do we need to continue dose escalations wtih DA REPOCH after a negative interim PET scan for PMBCL?
What is your preferred salvage chemotherapy regimen for bridge to auto SCT for patients with relapsed classical Hodgkin Lymphoma?
We actually have been favoring using a bendamustine-brentuximab based regimen (in those who have not received brentuximab in the front line setting). Supportive data is based on Lancet Oncol. Feb 2018 that showed a favorable toxicity profile with an almost 80% ORR. Usually will give 2-3 cycles, rest...
Would you discontinue dabrafenib/trametinib in a patient with BRAF mutant metastatic lung cancer if you see mild cardiomyopathy which could be related to the drugs?
This is a good question and a clinical scenario that I just recently ran into. The main question relates to the degree of LVEF change and whether the patient is symptomatic or not. It is not that uncommon overall. In the phase 2 trial of dabrafenib and trametinib that led to approval of this regimen...
How do you think about management options in a patient with a minute focus of Gleason grade 4 (4+4) on 1 core from needle biopsy along with only Gleason 3+3 disease in other biopsy cores and PSA<10?
This patient has "Favorable High Risk Prostate Cancer", and has outcomes similar to an intermediate unfavorable risk patient, rather than a true high risk patient. See here.I would offer this patient at least 6 months of ADT with IMRT. It would not be wrong to offer a longer course of ADT (24 mo), b...
For rectal adenocarcinoma initially staged as T2N0 and treated with upfront surgical resection, but pathologically upstaged to pT3N0 without high risk features, how do you approach adjuvant therapy?
It is not uncommon for a rectal cancer which was initially felt to be T1-2 and node negative to be revealed to be more advanced stage after surgery. To know what to do in these settings, we have to go “old school” and revisit trials reported in the 1990s, combined with lessons learned in the 2000s.S...
For a patient with limited/resectable metastatic melanoma and no evidence of disease after resection, when would you consider doublet immunotherapy rather than nivolumab or pembrolizumab monotherapy?
This is an interesting question. I would say the standard approach would be to use anti PD1 alone. There was an interesting trial presented at ESMO 2019, the IMMUNED trial, that was a phase 2 randomized trial comparing the use of combination ipilimumab and nivolumab compared to nivolumab alone for r...
Would you consider the use of PARP inhibitors in patients with BARD 1 mutation and refractory pancreatic cancer?
I will use it.In a disease like pancreatic adenocarcinoma, where treatment options are so limited, one has a much lower threshold to think out of the box. Of course there is no good (or any) data on the use of PARPi in this particular setting. However, with the manageable toxicity of the PARPi, I wo...
Would you offer adjuvant TKI to patients with locally recurrent multifocal adenoid cystic carcinoma?
I would not give a TKI in the adjuvant setting following a local recurrence that was resected. The only data that we have with these agents are in the setting of metastatic disease. The likelihood of recurrence, I believe, would be quite high once the agents are stopped, as we do not know how long o...