Medical Oncology

NCI-CCC Tumor Board Question   

These are questions being discussed by academics at NCI-Cancer Centers

Questions discussed in this category



I am considering every 6 week pembrolizumab dosing in patients >70 years old in whom I want to reduce clinic visits for, especially in the context ...

Is there any evidence for sacituzumab govitecan (IMMU-132) in this situation with progressive systemic disease after prior anthracycline and taxane?

This patient underwent mastectomy and ALND (10/28 positive lymph nodes). Immediately following axillary LN dissection (and prior to radiation) imaging...

Data from the SOFT/TEXT trials showed clinical benefit in ovarian suppression + aromatase inhibition for high risk, premenopausal ...

Would you offer this patient chemotherapy? What are your thoughts about OFS plus AI and avoiding chemotherapy?

Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?

Would you consider genomic assays before neoadjuvant chemotherapy? How would you modify your treatment given the COVID-19 pandemic?

Upfront surgery vs neoadjuvant therapy? And if neoadjuvant therapy, which regimen? Patient has a good PS.

What are the risks of infection with COVID-19 if using immunotherapy?  

Should staging and treatment decisions be made based on imaging alone?

Personally, my practice is to guide patients directly to surgery or to do neoadjuvant chemotherapy rather than to do neoadjuvant endocrine therapy, bu...

For example, if you had a triple positive breast cancer found on breast biopsy and repeat ER/PR/HER2 testing at the time of surgical resection showed ...

This patient is interested in conceiving and therefore would like to wait to start the tamoxifen.

For example, if a patient had testosterone pellets injected, perhaps making endocrine therapy less efficacious, would that sway you to use chemo?

Being that this is a favorable histology would you use Oncotype Dx to help decide on neoadjuvant chemotherapy? Would you recommend neoadjuvant endocri...

In your experience, what approach has been successful to bridge to surgery?

Especially if you don't have trials available at the moment. Would you try off-label erdafitinib (given recent data on bladder cancer) or 2nd line ge...

If so, for what platelet count threshold and do you have a preference as to which agent?

Ampullary carcinoma is not in the NCCN guidelines. Please address not only the role for therapy but the optimal regimen (i.e. Gem based, vs mFOLFIRINO...

In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?

Knowing that benefit of contralateral mastectomy is lower in older women who has already manifested BRCA related cancer and 10-20 % mastectomy related...

What would be the next line of treatment, PRRT, capecitabine and temozolomide or other?

In a patient with lung cancer with both NSCLC and SCLC components, would you offer carbo/pem/pembro or carbo/etoposide/atezolizumab? Or any other alte...

The NCCN guidelines regard  MET exon 14 skip mutation   as an emerging biomarker but no formal recommendation to start crizotinib. If high P...

If yes, would you still recommend dual HER2 directed therapy? After the TRYPHAENA trial, neoadjuvant therapy with dual HER2 directed therapy has beco...

Given that DBA is associated with increased incidence of MDS, AML and other solid tumors, would this modify your treatment recommendations?

For early stage disease in a single breast, would you consider neoadjuvant chemotherapy or upfront surgical staging followed by adjuvant therapy? What...

Given the potential high risk of developing pneumonitis with TKI post checkpoint inhibitor, do you avoid TKIs and try a different regimen (ex carbo/pa...

Provided the sternal lesion was low volume and treated with curative intent and patient has been on tamoxifen for < 5 years, would you switch to AI...

Following SRS to the brain lesions, is it safe to closely follow the patient for recurrence?  

Tamoxifen prophylaxis has not been studied in women <35 years old, but it would be reasonable to assume they would benefit.

In a patient with who had undergone neoadjuvant TCH-P, lumpectomy, and RT and is currently on AI, pertuzumab, and trastuzumab, how do you think about ...

In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial. https://www.ncbi.nlm.nih.go...

Why do the NCCN guidelines suggest using neoadjuvant therapy only for patients with T2 or greater tumors?

 If so, would you treat as node + BC with  anthracycline and taxane regimen or   non-anthracycline regimen (i.e  docetaxel and cyc...

Retrospective data suggest clinically significant disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung canc...

The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...

Is there a point at which there may be no benefit? More than 3 months from breast surgery? 6 months? 1 year?

Would you maintain dose density of chemotherapy and use peg-filgrastim prior to delivery of the baby? Would you defer taxane and anti-HER2 therapy unt...

If so, what would be the regimen that you would consider and what factors would sway you for or against chemotherapy for such patients?

No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.

Do your recommendations differ if patients are pre or postmenopausal given the data?

Does the answer vary based on whether it is neo/adjuvant or metastatic setting?

Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?

 Ex. TP53, BRCA, T790M, or another? As of now, T790M mutation is one of the few de novo mutations found in treatment naïve patients  th...

Is there any role for denosumab? How do you counsel patients regarding the benefit of bisphosphonates on breast cancer outcomes?

There is no evidence of disease outside the lung on PET, and the patient is completely asymptomatic with negative EGFR, ALK, ROS1, and BRAF and a PD-L...

PD-L1 < 50% and no targetable mutations. Would you use carbo/pemetrexed/pembrolizumab or Nivolumab or pembrolizumab?

Lung primary is inaccessible for biopsy and metastatic sites are only 2 small bone lesions. In a non-smoker, a driver mutation is suspected but would ...

In a patient treated over 10 years ago with mastectomy and chemo now with recurrence in the ipislateral axilla, would you offer additional with chemot...

Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...

Would you do this for ER+ patients? According to the PERSEPHONE trial presented on ASCO 2018, in HER2+, non-metastatic breast cancer, 6 months Hercep...

If there is no response to neoadjuvant AC -->T, would you offer additional adjuvant chemotherapy?

High enough risk to justify anthracycline+taxane chemotherapy followed by ovarian suppression + aromatase inhibition.

Do you offer additional adjuvant chemotherapy, proceed to adjuvant endocrine therapy, or search for a suitable clinical trial?

Patient does not qualify for breast cancer screening by annual MRI per criteria (IBIS lifetime risk<20%, no known genetic predisposition,...

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

Would you treat this as a locally advanced breast cancer and offer surgery, radiation, and systemic therapy? Does your management change depending on ...

These patients have been largely excluded from these trials.  What if the infection is well controlled?

An article (BRCA mutation and outcome in BC. Ellen Copson, et al. Lancet Oncol. 2018) showed G3, BRCA+ breast cancer had poorer prognos...

If so, when? Are there certain ERBB2 mutations that would predict response to trastuzumab and/or neratinib? 

Following the dosage guidelines based on absolute neutrophil count may cause the patient to end up receiving lower doses.

This is in regards to the risk of secondary cancers after radiation therapy or cytotoxic chemotherapy (such as anthracyclines) in an immunosuppre...

What do you do with low grade (grade 1/3) tumors? In other words, does high grade pathology over rules?

Would you use a regimen with lower incidence of neurotoxicity such as CMF or a taxane-based regimen with a low threshold to dose-reduce?

Some patients request chemotherapy scheduling adjustments to avoid feeling ill on major holidays. Delaying chemotherapy by a few days isn't of particu...

Example case: Patient given neoadjuvant docetaxel + cyclophophamide achieves a partial response after 3 cycles of Taxotere + cyclophosphamide but is u...

Tamoxifen prophylaxis is FDA-approved, but would you extrapolate from adjuvant/metatastic data for hormone receptor positive breast cancer in post-men...

In the absence of data demonstrating a clinical benefit for one strategy versus the other, what do you do in practice?  

Given the data noting predictive benefit of utilizing genomic testing in predicting later relapse of hormone receptor positive breast cancer.

There is limited data that suggests steroidal AI exemestane could be of some benefit after nonsteroidal AI failure (Lonning PE et al. J Clin Oncol 200...

I.e. either for treatment of high-risk disease or intolerance/contraindication to tamoxifen. Will you continue it for the full 5 year course?

Aside from local therapies (intrathecal, radiation), are there therapies that are known to have better CNS penetration?

Do you reserve this approach for only women with triple negative breast cancer or all-comers?

What would you choose if there is no response to neoadjuvant AC-T? Taxol, THP, TCHP?

(For instance, TCX4 instead of AC->T for smaller tumors?)Does this affect your decision about treating with neoadjuvant versus adjuvant chemotherap...

At what point do you send these test, and in what instances do the results influence your treatment recommendations?


Papers discussed in this category


International journal of radiation oncology, biology, physics, 2013-03-15

International journal of radiation oncology, biology, physics, 2011-05-01

International journal of radiation oncology, biology, physics, 2011-11-01

The New England journal of medicine, 2015-03-05

N. Engl. J. Med., 2015-01-29

Lancet, 2007-05-19

The Lancet. Oncology, 2016-12

Nat. Med.,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-02-01

Clinical breast cancer, 2006-12

Lancet (London, England), 2009-12-19

The Lancet. Oncology, 2014-06

The New England journal of medicine, 2012-11-08

J. Clin. Oncol.,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2003-03-15

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2009-03-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-08-10

J. Clin. Oncol., 2019 Oct 16

N. Engl. J. Med., 2017-07-13

Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2015-04

Am J Case Rep, 2017-02-28

The New England journal of medicine, 2016-08-25

N. Engl. J. Med.,

Lancet, 2017-09-09

Annals of oncology : official journal of the European Society for Medical Oncology, 2013-09

Oncologist, 2007-09-01

Journal of the National Cancer Institute, 2006-12-20

Medicine and science in sports and exercise, 2010-07

J Clin Oncol, 2016 Feb 20

Curr Breast Cancer Rep, 2016-01-01

Crit Rev Food Sci Nutr, 2018 Apr 19

JAMA, 2018-02-20

JAMA Oncol,

The New England journal of medicine, 2012-08-02

Lancet (London, England), 2016-12-17

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-09-01

Breast cancer research and treatment, 2012-11

British journal of clinical pharmacology, 2016-06

The New England journal of medicine, 2014-07-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-07-01

Fertility and sterility, 2016-03

Breast Cancer, 2017-09-01

Journal of the National Cancer Institute, 2010-07-07

J Natl Cancer Inst, 2006 Jul 5

J. Natl. Cancer Inst., 2010-07-07

J. Clin. Oncol., 2003-10-01

Lancet (London, England), 2013-03-09

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-04-20

Journal of the National Cancer Institute, 2013-07-17

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-09-01

The New England journal of medicine, 2016-07-21

Breast Cancer Res. Treat., 2005-01-01

Breast, 2016-12-01

Zhonghua Zhong Liu Za Zhi, 2016-07-01

Breast, 2016-08-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-05-10

Cancer, 2010-11-15

The breast journal, 2017-11

The New England journal of medicine, 2011-06-23

Lancet (London, England), 2016-02-27

Cancer investigation, 2011-11

Clinical cancer research : an official journal of the American Association for Cancer Research, 2009-12-01

Cancer Treat. Rev., 2011-10-01

Annals of oncology : official journal of the European Society for Medical Oncology, 2015-07

Ann. Oncol., 2013-12-01

Nat Rev Clin Oncol, 2016-08-01

The Lancet. Oncology, 2018-02

Ann. Oncol.,

Clin. Cancer Res., 2018 Mar 26

Ann. Oncol.,

Breast Cancer, 2012 Apr 25

Annals of surgical oncology, 2018-10

Lancet Oncol., 2015 Sep 09

Cancer, 2004-10-15

The New England journal of medicine, 2018-12-13

Lancet Oncol., 2016 Jun 23

BMJ, 2016 Sep 30

The New England journal of medicine, 2018-07-12

Journal of the National Cancer Institute, 2017-02

N Engl J Med, 2015 Jan 8

Annals of internal medicine, 2018-01-16

N Engl J Med, 2017 Nov 16

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-12-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-04-10

The Lancet. Oncology, 2012-07

Annu. Rev. Med., 2015 Aug 28

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-06-20

The New England journal of medicine, 2018-07-12

Cancer, 2006-09-15

Cancer Discov,

Clin. Cancer Res.,

N. Engl. J. Med.,

The Lancet. Oncology, 2019-01

The Lancet. Oncology, 2017-12

J Thorac Oncol, 2016 Jul

Eur. J. Cancer, 2017 Aug 04

J Thorac Oncol, 2018 Feb

J. Clin. Oncol., 2018 Jun 15

The Lancet. Oncology, 2015-02

J. Clin. Oncol., 2017 Dec 14

NPJ breast cancer, 2017

The New England journal of medicine, 2018-06-14

N Engl J Med, 2018 Oct 20

The Lancet. Respiratory medicine, 2017-11

Ann. Thorac. Surg.,

Annals of surgical oncology, 2009-06

Annals of surgical oncology, 2017-02

Breast Cancer Res. Treat., 2017 Sep 15

JAMA, 2011-11-02

The New England journal of medicine, 2016-11-17

The Lancet. Oncology, 2016-04

Breast cancer research : BCR, 2016-06-28

J Clin Oncol, 2011 Jan 10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-01-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-07-20

JAMA Oncol,

N Engl J Med, 2014 Sep 27

Clinical cancer research : an official journal of the American Association for Cancer Research, 2016-09-15

J. Clin. Oncol., 2018 Mar 29

JAMA Oncol,

J. Clin. Oncol., 2020 Feb 20

The New England journal of medicine, 2016-11-10

The New England journal of medicine, 2018-05-31

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-03-01

The Lancet. Oncology, 2013-10

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2000-04

N Engl J Med, 2011 Oct 6

Lancet Oncol., 2012-01-01

Annals of oncology : official journal of the European Society for Medical Oncology, 2013-09

JAMA oncology, 2017-05-01

J. Clin. Oncol., 2017 Oct 02

The New England journal of medicine, 2015-02-19

Breast Cancer Res Treat, 2009 Jun

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2019-02

JAMA, 2012 Jul 11

Radiation oncology (London, England), 2011-09-28

JAMA surgery, 2019-05-29

J. Clin. Oncol., 2020 Feb 27

Trials, 2013 Aug 19

Ann. Oncol., 2012 Jun 06

Cancer,

Clin Transl Oncol, 2018 Mar 28

N. Engl. J. Med., 2017 Jun 04

Clinical cancer research : an official journal of the American Association for Cancer Research, 2017-04-15

The New England journal of medicine, 2019-06-20

The New England journal of medicine, 2018-01-11

N. Engl. J. Med., 2019 May 31

The New England journal of medicine, 2018-12-06

J Thorac Oncol, 2019 Jan 18

The New England journal of medicine, 2019-02-14

N. Engl. J. Med.,

The New England journal of medicine, 2012-02-09

Cancer control : journal of the Moffitt Cancer Center, 2009-01

JAMA, 2015-07-07

Clinical cancer research : an official journal of the American Association for Cancer Research, 2019-08-01

Nat Commun, 2019 Mar 27

Annals of surgery, 2019-04-05

The Lancet. Oncology, 2010-01

Breast Cancer Res. Treat.,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-09-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2004-06-15

J. Natl. Cancer Inst.,

PLoS ONE, 2018 May 16

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-08-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2013-07-01

Lancet Oncol., 2015-03-01

Ann. Surg. Oncol., 2013 Nov 23

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-01-01

Lancet Oncol., 2014-06-01

Clinical cancer research : an official journal of the American Association for Cancer Research, 2017-02-01

Breast, 2013 Dec 22

Breast, 2015 Oct 09

Cancer,

J. Clin. Oncol., 2013 Aug 26

JAMA, 2014-05-21

Annals of oncology : official journal of the European Society for Medical Oncology, 2019-08-01

Cancer, 2005-04-15

Cancer, 2017-11-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-08-20

Lancet (London, England), 2019-05-04

N. Engl. J. Med., 2019 Sep 28

Clin. Cancer Res., 2019 Aug 15

Ann. Oncol.,

Gastroenterology, 2018 May 17

Clin. Gastroenterol. Hepatol., 2018 Nov 28

Hepatology (Baltimore, Md.), 2019-10

Cancer, 2011-11-01

Case reports in oncology, 2017

BMC Cancer, 2015 Oct 15

JAMA oncology, 2019-06-01

Int J Cancer, 2018 Apr 15

JAMA Oncol, 2019 Oct 31

Eur J Surg Oncol, 2014 Oct 07

Breast cancer research and treatment, 2017-08

Ann. Oncol.,

The Lancet. Oncology, 2018-01

Annals of surgical oncology, 2018-08

Lancet Oncol., 2020 Feb 14

The Lancet. Oncology, 2010-10

Breast Cancer Res. Treat.,

Lancet, 2019 Oct 04

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-04-20

Cancer discovery, 2015-08

Annals of oncology : official journal of the European Society for Medical Oncology, 2018-10-01

Nature, 2014-07-31

Cancer discovery, 2015-08

J. Clin. Oncol., 2019 Oct 16

Proceedings of the National Academy of Sciences of the United States of America, 2015-11-03

Oncologist, 2020 Mar 10

Semin Diagn Pathol, 2016 Dec 23

Breast cancer research and treatment, 2014-11

The Lancet. Oncology, 2016-03