Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Has NRG-CC009 changed your approach to offering SRS over HA-WBRT as the preferred treatment for patients with brain metastases from small cell lung cancer?
Yes, it has. The authors and NRG are commended for completing this pivotal trial. We were offering MDACC SRS in select cases based on an ongoing clinical trial there as well. NRG-CC009 trial will establish a standard for SRS as the preferred modality for patients with SCLC in cases where patient sel...
How do you choose between ADT/Abiraterone/Capivasertib vs other triplets for fit patients with de novo high-volume mHSPC and near-complete PTEN loss?
Based on prospective randomized controlled trials, the only treatment that has proven benefit in this setting is the triplet with ADT/abiraterone and Capivasertib. I like this combination in particular for fit patients because the side effect profile should allow them to continue to maintain their f...
What is the role of liquid biopsy in patients with metastatic castration resistant prostate cancer to asses BRCA1/2 or other mutations and consider PARP inhibitors?
There are no FDA cleared tests that have been shown to accurately predict response or benefit from PARP inhibitors in men with prostate cancer. The risk of both false positives and false negatives remains high with these assays due and no studies in prostate cancer have shown concordance with a high...
How do you sequence radiation and capecitabine in breast cancer patients receiving adjuvant capecitabine for residual disease after neoadjuvant chemotherapy?
According to personal communication with Dr. Masakazu Toi (June 13, 2017), the corresponding author of the CREATE-X NEJM publication, radiotherapy was administered prior to capecitabine in the majority of cases on this study. It is worth noting that in CALGB 49907, a randomized trial comparing capec...
Do the results and approval based on ADAURA trial suggest a role for adjuvant osimertinib in patients with stage IIIB-C, EGFR mutant patients treated with concurrent chemoradiation?
ADAURA trial was not designed to address this issue. But that being said, we need to remember few things before considering "maintenance durvalumab" in patients with EGFR-mutant lung cancer, following chemo-radiation: 1. EGFR-mutant NSCLC patients may not derive any clinical benefit from single-agen...
How would you treat a patient with metastatic NSCLC on pembrolizumab with a sustained complete response, now with 2 isolated small liver lesions?
I am unaware of any "level 1" evidence for this approach, much of our data is anecdotal, however there is certainly reasonable experience of treating "oligo-progressive" disease with local therapies. While there is more experience in adrenal and CNS metastatic disease, I would think that a local the...
Would weak PR positivity make you consider adjuvant endocrine therapy for a young pre-menopausal woman with a HER2 positive, ER negative breast cancer?
I would discuss the uncertainties, and would offer tamoxifen at the most (I would not subject the patient to the toxicities of OFS and AI). I would also have a low threshold to discontinue tamoxifen if there are toxicities. If there are minimal to no side effects, it may be worthwhile getting the th...
When do you recommend PD-L1 testing for patients with recurrent cervical cancer?
I think getting the testing done as soon as possible is best because very few patients will only need first line therapy. This way, there is less of a delay at the time of progression following/during first-line therapy.
In light of GOG-252, are there any situations where IP chemotherapy would be preferable following debulking of advanced epithelial ovarian cancer?
In GOG-252, the control arm (arm 1) was the dose-dense Japanese GOG (JGOG) regimen, compared to two IP-based arms (arm 2, IP carboplatin, and arm 3, IP cisplatin). As stated in our OGR, interpretation of the negative results of this study is difficult for several reasons. All three arms in GOG-252 r...
When discussing immunotherapy with patients, how do you frame the conversation in a way that acknowledges the fact that many patients do not respond but allows for hope for a durable response?
There is certainly more than one way to do it. The best way depends on knowing the learning style and information preferences of your patient and then tempering information that they need to have to be informed appropriately. The Shared Decision Making [SDM] model encourages us to invite the patient...