Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...
How does the POSEIDON meta-analysis results influence your decision on which patients should receive hormone therapy with post-operative radiotherapy for recurrent prostate cancer?
POSEIDON is another landmark analysis from the MARCAP consortium. It adds to the seminal work performed in localized prostate cancer (Kishan et al., PMID 35051385), which serves as the reference study for the use and duration of ADT with radiotherapy, but now in the post-prostatectomy setting.The st...
Do you recommend frontline bevacizumab with carbo/taxol in patients with advanced epithelial ovarian and BRCA mutation who will be receiving olaparib maintenance?
As shown in GOG-218, there is no apparent benefit to using concurrent bevacizumab with paclitaxel and carboplatin in the first-line setting, if this drug is not then continued during maintenance therapy. Our approach is to obtain genetic testing in patients with epithelial ovarian cancer as soon as ...
How will the ADAURA study impact your use of adjuvant chemotherapy?
ADAURA has not and will not impact my use of adjuvant chemotherapy. Many prospective studies have demonstrated a clear significant improvement in overall survival with the use of adjuvant chemotherapy after complete surgical resection. This is standard of care for the appropriate patients. Osimertin...
Would you recommend sentinel lymph node biopsy at the time of wide excision for a 3 mm Merkel cell carcinoma of the cheek/lateral canthus?
Unlike melanoma and certainly NMSC, MCC is highly unpredictable in nature, with clinical lesion size having little clinical prognostic value. As such, it appears that SLNB is valuable in many cases for the purposes of prognosis and in determining the need for adjuvant systemic therapy and radiation....
Would you consider adjuvant immunotherapy for a patient with high-risk Merkel cell carcinoma following definitive surgical resection and adjuvant radiation therapy?
Although there is no level 1 data supporting adjuvant RT in MCC, a relatively recent meta-analysis from an Italian group (Petrelli et al., PMID 31005218) showed that adjuvant RT is associated with a 75% reduction in local and locoregional relapses versus surgery alone, without a reduction in distant...
How long do you continue trastuzumab and pertuzumab after lumpectomy if you included both in a neoadjuvant regimen such as TCH-P?
A total of one year for trastuzumab, including the part with chemotherapy, adjuvant or neoadjuvant. The benefit from addition of pertuzumab, as might have been predicted, was very small, since it is very hard to add any sizable benefit to trastuzumab without some logical risk stratification; for ER ...
How do you decide on the duration of endocrine therapy for premenopausal women who receive chemotherapy and AI/ovarian suppression according to TEXT/SOFT?
Women who have a higher than average risk of recurrence (those who receive chemotherapy, younger than 35 Years, stages II or III ....) derive the most benefit from endocrine therapy +ovarian suppression (using monthly GNRH agonists) for 5 years based on TEXT and SOFT in DFS. The joint analysis of SO...
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...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...