Medical Oncology

Gastrointestinal Cancers   

Questions discussed in this category

Would chemotherapy alone suffice? Repeat biopsy and EUS were negative for residual disease.

In a patient who is not a surgical candidate, do you offer concurrent carbo/taxol rather than 5FU/oxaliplatin? 

Does the advent of more effective therapies like peptide receptor radioligand therapy (PRRT) and capecitabine and temozolomide (CAPTEM) dampen enthusi...

Do you use the same high risk factors as adenocarcinoma when deciding on adjuvant treatment for early stage disease?

What parameters do you use to decide to treat beyond progression? Is there any efficacy data from this specific study subgroup in IMbrave150?

If so, how many cycles would you give? Both the MAGIC and FLOT trials showed difficulty with administering adjuvant chemotherapy.

Or would you consider IO agent be given only after progression on platinum + fluoropyrimidine?

The patient went straight to gastrectomy for clinical T1 gastric adenocarcinoma, but post-op was up-graded to T4 disease.   Both ARTIST and Inte...

Has the recent approval of atezolizumab/bevacizumab impacted your decision making? 

Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?

The upfront plan is to use a definitive radiation dose of 66 Gy. My reading supports the use of 5FU + cisplatin but another doctor is recommending FOL...

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 ...

How would the sidedness of the tumor, BRAF, RAS,HER2 or MSI status affect your decision?

For a patient not on dialysis? Outside of single agent 5FU, all other standard chemotherapeutic options would be contraindicated for nephrotoxicity.&n...

Patients oftentimes have cardiac co-morbidities with requirement for anti-coagulation making TKIs, including Bevacizumab, difficult to dose. Would the...

Would you use a small cell regimen over a more traditional FOLFOX-esque approach?

When using short course RT, the NCCN guidelines currently recommend short course RT followed by chemotherapy, followed by surgery. Many surgeons are h...

Would you use dual agent chemotherapy such as FOLFIRI, combination of chemo with biologic- IRI/Cetux or all 3 drugs simultaneously? How would sidednes...

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

Quite often we encounter cholestatic hyperbilirubinemia, wherein GI and IR do not believe ERCP with stents or PTC will alleviate jaundice. If the pati...

Would you treat with typical small cell paradigms such as surgery followed by adjuvant platinum doublet +/- radiation vs definitive chemoradiation? Or...

If so, what dose-fractionation regimen do you utilize? What are your target volumes?

Given that majority of benefit is derived from the capecitabine, would this be an acceptable option to decrease patient contact with the healthcare sy...

Would presence of features considered high risk in stage II sway your interpretation of the IDEA trial? 

With extensive use of NGS testing, it is commonplace to identify mutations that have no validated therapeutic intervention, but strong biologic signal...

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

Up to six cycles of treatment were given in the ABC02 trial.  Do you offer other treatments if you don't continue gem/cis beyond 24 weeks?

Of note, CLASSIC (Noh; Lancet Onc 2014) nor ARTIST (Lee; JCO 2012) evaluated other histologic subtypes, is the approach to treatment any different tha...

In light of the results of the ESPAC-4 trial, is combination gemcitabine plus capecitabine being considered over single agent gemcitabine for adjuvant...

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 practice, does starting with chemoradiation followed by chemotherapy result in a significant delay in initiating chemotherapy or a patient's abilit...

Would the presence of peritoneal carcinomatosis change your treatment strategy? If Ki-67 <50%, would you avoid platinum based cytotoxics?

The German trial included patients with tumors up to 16cm from the anal verge, while the Swedish trial update found no local control benefit for tumor...

Given the variable and sometimes indolent disease course of these patients, as well as the absence of a clear overall survival benefit in the PROMID&n...

Would you approach with curative intent with locoregional treatment or systemic treatment alone?

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

Is there a "best" way to approach treatment of the viral infection i.e concurrently with therapy, prior to therapy, delayed or post therapy? Does this...

If you do employ this strategy, are there a number of liver lesions (eg <4) or duration of response that guide your decision making?

Would you alter your SBRT dose? How long would you hold the VEGF inhibitor before and after? Does the primary matter (e.g. NSCLC vs. colorectal)?

A number of phase 2 trials support various combinations (e.g. gem/ox, cape/cis, cape/ox, 5-FU based) -- how do you decide either between these regimen...

The NCCN seems to make its recommendation based on extrapolation from colon cancer, but those patients are not treated with pre-op chemoRT.

How do you choose between local therapy (surgical debulking or ablation) v. 2nd line systemic therapy? Would you consider immunotherapy?

Would presence of TP53 mutation weigh in on the offer of radiation? Would there be any change expected on the chemo regimen?

Would you consider adding trastuzumab to cis/gem in the first line? If not, would you consider adding Her2 directed therapy to FOLFIRI or FOLFOX in th...

Do you continue with FOLFIRI for a period and then switch to olaparib (and if so, when do you make that switch) or do you switch directly after FOLFIR...

Does the precise location of duodenal cancer even matter given that treatment would be 5FU/platinum based. Also with the knowledge of impact of sidedn...

On occasion, patients with locally advanced gastric cancer are poor candidates for FLOT-like chemotherapy. Should such patients be taken to surgery up...

Has the utility of BRAF in CRC expanded beyond guiding prognosis? Is there a role in non-metastatic CRC?

Patient characteristics would unarguably be a deciding factor, but outside of these how would you approach the situation?

Exploratory analysis of the MAGIC trial suggested perioperative chemotherapy was detrimental in this subset of patients. Has availability of IO altere...

There is some data on TMZ and 5FU based regimens, but convincing evidence is lacking. How would you approach this situation?

For instance, in borderline cases for neoadjuvant therapy (e.g. T2N1 disease), should both be obtained to increase accuracy?

There is increased stroke risk after 65 years of age with bevacizumab. Does that stop you from using it?  

KEYNOTE-062 showed deep durable responses are possible with upfront pembro, specifically in the CPS >10 subset, with OS advantage when compare...

For those that do receive adjuvant therapy with stage II disease, we know magnitude of benefit to be lower.  If the decision is made to administe...

Do you offer perioperative chemo with metastectomy with an isolated liver metastasis? The RENAISSANCE/AIO-FLOT5 trial (PMID:30448343) is seeking to an...

For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...

When 5FU is a backbone to so many regimens, when (if ever) do you consider re-challenging so as not to abandon an entire line of therapy?

This is specifically in regards to metastatic colon cancer with good disease control of disease on FOLFOX and preserved hepatic function.  

What would be the optimal sequence of surgery, radiation, and chemotherapy for this patient? This patient has an excellent performance status and...

What features would make you more likely to recommend radiation therapy with chemotherapy?

Does the lack of D2 dissection automatically necessitate adjuvant chemoradiation therapy (ie <5 LN obtained)? Would the presence of high risk facto...

I have seen favorable clinical trial reports on dasatinib for metastatic disease, but no data on possible adjuvant use.  NCCN guidelines suggest ...

For a patient with cT3-4N0 rectal cancer, does the dose of the previous RT affect your decision making (for example, 45 Gy to the pelvis with boo...

Currently, nivolumab is approved as a second line systemic therapy for patients with metastatic HCC with Child-Pugh (CP) A-B7 based on results fr...

How do you approach a decision to retry a previously failed therapy if patient does not wish to pursue a clinical trial? Does sidedness (left or right...

Do you offer chemotherapy upfront in all patients or only if borderline resectable/unresectable?  If you treat, what regimen do you use and how l...

What would you consider in the first and second line settings with intact MMR/MSI?

Which neo-adjuvant or peri-operative chemotherapy regimen would you choose? NCCN guidelines recommend FLOT or FOLFOX in the peri-operative setting vs....

Would you start with a modified dosing scheme [i.e. Irinotecan (135mg/m2) and drop 5-FU bolus] or start at full dose FOLFIRINOX and then dose reduce b...

Based on the UK OnCoRe matched cohort analysis, would you offer a watch-and-wait approach off protocol or are you uncomfortable treatin...

Would you switch chemotherapy regimens (i.e if the patient received FOLFOX/Avastin, change to FOLFIRI/Avastin)? Would you treat wuth immunotherapy per...

Would you consider repeating neoadjuvant chemo/RT? Does this, occurring in the context of Lynch Syndrome, change the treatment approach?

Does presence of intraperitoneal spread and solitary extraperitoneal visceral metastasis affect management?

Can you comment based on the results of PRODIGE 24 from ASCO 2018?

Do you start with 1250 mg/m2 BID and then dose reduce based on toxicities? Many studies across varied types of malignancies have shown good tolerabili...

If the patient has large, bulky nodes would you consider starting after chemotherapy for cytoreduction? Or otherwise consider replanning mid-treatment...

5FU/mitomycin C or 5FU/cisplatin? Is there any benefit of cisplatin in terms of skin toxicity?  

Would you consider referring the patient for HIPEC at some point in their treatment, possibly after giving adjuvant chemotherapy, especially if patien...

What factors dictate choice of observation versus 6 months of adjuvant peri-operative chemoradiation plus chemotherapy especially if patient did not r...

Taking into account the overlap between treatment regimens for esophageal and gastric cancers, in what clinical context might you feel comfortable tre...

NCCN lists CRT as category 1 but also lists chemotherapy alone as an option.  Is this decision based on discussion between surgeon and oncologist...

The abstract of the pooled meta-analysis is not definitive (JCO 35, 2017: suppl; abstr LBA1), and of the phase III trials (SCOT, TOSCA, Alliance/SWOG ...

If a patient with stage II or III colon adenocarcinoma who presents to your clinic 12-16 weeks after surgical resection do you give adjuvant chemother...

Does HER2 or PD1/PDL1 positivity change first line treatment (i.e. preferential enrollment on clinical trials) or do such patients still receiving sta...

The GTX (gemcitabine, docetaxel, capecitabine) regimen is listed as a category 2B recommendation in the NCCN guidelines- when would this be ...

Since immune check point inhibitors have been approved for GEJ and gastric cancer, would a distal esophogeal adenocarcinoma be considered GEJ or does ...

Would you consider subtotal gastrectomy vs medical therapy?

Most oncologists are comfortable offering FOLFOX for 1st line metastatic adenocarcinoma. Would you be comfortable offering FOLFOX to met. squamous eso...

Is there a change in approach over the past few years? Would there be a role for the 12-gene recurrence score?

NCCN puts "preferred" regimens but only category 1 is cisplatin and fluoropyrimidine. When would you use that regimen over FOLFOX?

In a patient who developed oligometastatic disease before completing adjuvant XELOX, what treatment(s) and duration of treatment would you recommend?

I have a few patients with kras braf mutation negative metastatic colon cancer treated with upfront FOLFOX- bev followed by 5FU-bev who had regression...

When PDL1 expression is negative, but IHC for mismatch repair expression is consistent with mismatch repair deficiency (MLH2, MSH2, and MSH6 expressed...

NCCN discusses targeted therapies (Everolimus) but also Temodar / Xeloda combination.

Regorafenib has been approved for patients with advanced HCC post-sorafenib, but the benefits are slight and toxicity substantial.  Nivolumab has...

Given recent FDA accelerated approval of pembrolizumab for MSI-H tumors regardless of site of origin, does it make sense to apply MSI testing, in...

If biopsy of the lesion is consistent with GI origin adenocarcinoma and there are no other sites of disease, would wedge resection followed by adjuvan...

Does your management differ if the hiccups are felt to be related to chemotherapy as opposed to the disease itself?

Tumor involves stomach, liver, and lymph nodes. Pathology is suspicious for sarcomatoid carcinoma, possibly sarcomatoid cholangiocarcinoma.

In LAP07's second randomization (capecitabine+54 Gy vs maintenance gemcitabine +/- erlotinib), 60% of unresectable pancreatic cancer patients who did ...

If a patient developed locoregional recurrence after initial chemoradiation, would resection of known disease followed by observation be preferred?

With the current data, I'm struggling to justify addition of radiation for potentially resectable disease.  If in favor of RT, do you recommend s...

Would you use 5-FU and radiation alone? Would your management be different for loco-regional (curative) vs metastatic situations?

How do you weigh the recently presented/published data from the NETTER-1 and RADIANT-4 trials in your decision making?

Is salvage liver resection considered the next step in treatment for patients who may have resectable tumors after TACE?  If so, do specific tumo...

Is MRI being considered the primary mode of imaging in multidisciplinary tumor boards, especially in light of the results of the MERCURY trial (JCO 20...

In your practice, has tumor molecular profiling in pancreatic cancer led to the identification of any actionable targets for which a patient was put o...

Does the location of the pancreatic mass respective to the major vessels alter initial management (surgery, chemotherapy, radiation,  or some com...

Do you have a preference for Regorafenib or Lonsurf or do you refer to clinical trials immediately given the known low response rates to these drugs?&...

Would you consider HER-2 directed therapy (lapatinib-trastuzumab)? Does being KRAS-mutated affect your decision? 

Would taking the drug at a specific time point prior to their radiation appointment time to maximize blood levels of the drug be clinically beneficial...

Do you treat with standard of care therapy for microsatellite stable (MSS) colorectal cancers or pursue further work-up? Does this differ between adju...

Since some prior subset analyses have suggested that oxaliplatin may not improve outcomes of older patients with colon cancer in the adjuvant settin...

Does the recent Hopkins trial of pembrolizumab change your management of these patients?

Should oxaliplatin/capecitabine alone be the standard of care?

In a patient with an R0 resection, would you routinely recommend postop chemoradiation, since these patients were included in the MacDo...

Papers discussed in this category

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