Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?
The trial allowed both treated and untreated brain mets, and showed response rate and improved survival. If the patient is not a candidate for SRS, it’s reasonable to watch brain lesions with serial MRIs.
Would you offer salvage chemotherapy to a patient with stage IIIC poor risk NSGCT in whom AFP fail to normalize even after 2 months of completion of 4 cycles BEP?
It depends on the absolute value and the trend of elevated AFP. Low level AFP elevation (usually in the teens) is common and difficult to accurately interpret the abnormality. If the AFP is not rising, I probably proceed to post-chemo RPLND as the first step. Also, sometimes people proceed to chemot...
Is there a role for maintenance lenalidomide after non anthracycline regimens in elderly patients with DLBCL?
Lenalidomide maintenance prolonged PFS among elderly patients with diffuse large B-cell lymphoma who had achieved partial or complete response to standard therapy (RCHOP), according to results of the phase 3 REMARC trial. It did not translate into OS advantage in the experimental arm. I would discus...
Would you use a NTRK TKI for a patient with metastatic HR+, HER2- breast cancer with a complex NTRK3 gene re-arrangement on Foundation testing?
While it's difficult to give an answer without knowing details of the fusion event, I would point to the potential for immunohistochemistry for Trk as an orthogonal method for identifying Trk expressing cancers with potential for testing Trk inhibitors. I would point to this paper for further inform...
Do you change systemic endocrine therapy for a patient who progresses only in the brain after SRS for metastatic HR+ breast cancer?
No, I would continue the same hormonal therapy until systemic progression. The brain is a sanctuary site. Disappointing that abemaciclib did not prevent since it crosses b-b barrier.
How do you manage TKI induced secondary polycythemia in a patient with RCC?
Fortunately this is fairly rare, although this has been described especially with axitinib. Polycythemia can also be RCC-related. I usually will engage my benign Heme colleagues who can help with the work up to ensure there are no other causes, and also direct phlebotomy as needed. I'm not aware thi...
What adjuvant therapy would you recommend to elderly patients with pT2N0 ER-/PR-/HER2+ breast cancer?
Yes, I agree you are a little outside the data zone here with a T2 tumor. However, for a patient over the age of 70 with comorbidities, I think paclitaxel/trastuzumab would be a very reasonable option and many of these patients elderly patients do not do well with TCH at standard dosing. I think aft...
How would you approach the treatment of cytopenia related to NK cell LGL leukemia?
You could use filgrastim and erythropoietin but I prefer to treat the underlying leukemia with low dose methotrexate or cytoxan. It may take up to 6 months to see responses to cytotoxic agents and you would need to support the patient during this time with transfusions or growth factors. Thrombocyto...
Would you discontinue anticoagulation in patients with antiphospholipid antibody syndrome, who have a remote history of thrombotic events and are now negative for pathogenic antiphospholipid antibodies?
I would certainly consider stopping anticoagulation in selected patients after an in-depth discussion about potential risks and benefits. I would not consider stopping AC in patients with a history of recurrent events, arterial events, or multiple risk factors for thrombosis (e.g. nephrotic syndrome...