Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you recommend re-excision of a unifocal positive anterior margin at skin after lumpectomy in a patient with otherwise low risk breast cancer features?
There are few data on how margin location affects outcome. A group from Dundee and Perth in Scotland reported that re-excision performed for an anterior margin of less than 1 mm found residual disease in only 4% of patients who had initial excision in the subcutaneous plane, compared to 24% of patie...
How do you treat Stage IIIC T4N3 NSCLC?
Probably need a bit more information since T4 is fairly heterogeneous, but it is absolutely treatable. If it involves both ipsilateral lobes, then SBRT to one isolated lesion and CRT for the rest is one approach. If T4 is involved in critical mediastinal organs, probably some induction therapy with ...
How do you approach the discussion about the potential risks of radiation therapy exposure and the development of secondary malignancies for patients with germline BRCA1/2 mutations?
It appears that the risk of secondary malignancies due to radiation exposure does not seem significantly enhanced in gBRCA-m carriers, unlike patients with Li-Fraumeni syndrome (for whom we would attempt to avoid radiation). The data on mBRCA-associated breast cancers would suggest that radiation is...
For an elderly woman with a platinum-resistant recurrence of a high-grade serous ovarian cancer who has been rendered NED surgically, is observation a reasonable approach?
Based on her age, performance status, and goals of care, it is certainly reasonable to discuss all options with patients. With her being platinum resistant, I would counsel on prognosis and the need to consider quality of life. With the need for balance between QoL and OS, waiting until there is a m...
How do you sequence targeted therapy and immunotherapy in patients with metastatic lung adenocarcinoma with EGFR exon 20 insertion mutations?
EGFR insertion 20 mutations are a rare subset of adenocarcinoma (1-2%). Patients with disease characterized by these mutations do not respond to EGFR TKIs such as osimertinib. Until recently, the standard first-line therapy for such patients was chemotherapy alone, typically carboplatin/pemetrexed. ...
What adjuvant systemic therapy would you recommend for a premenopausal woman with a germline BRCA mutation who initially presented with locally advanced, HR+, HER2-negative (FISH) IDC, but was later found on surgical pathology to have HR+, HER2+ disease (IHC 3+) after neoadjuvant chemotherapy?
In a situation like this, I would consider 1 year of adjuvant trastuzumab and pertuzumab. The HERA study showed the benefit of adding trastuzumab after a full course of adjuvant chemotherapy for HER2+ breast cancer, which would provide some (although imperfect) evidence to support such an approach. ...
How would you treat an unresectable epithelioid angiosarcoma invading the cavernous sinus, wrapping around the carotid artery?
Stage with PET and MRI. If any concern for intradural spread, complete spine imaging and consider LP to r/o LMD. Start with neoadjuvant taxane-based chemotherapy, potentially in a doublet (e.g., gem/tax). Then definitive CRT with concurrent taxol and conventional fractionation to 70 Gy, while respec...
For patients who require aggressive debulking in multiple myeloma, what is your preferred chemotherapy regimen and why?
I prefer VDPACE or KDPACE +/- lenalidomide, for EMD and aggressive myeloma! Our team has good data retrospectively even in patients heavily treated and who are triple RRMM. There are no prospective data, but happy to collaborate to seek retrospective data to compare efficacy and safety in this popul...
Do you recommend utilizing daratumumab in the maintenance phase after a quadruplet induction for transplant eligible multiple myeloma?
Great question as always - both the Phase 2 GRIFFIN study (Dara-VRd vs VRd using IV Dara and 21-day induction cycles) and the Phase 3 PERSEUS study (Dara-VRd vs VRd using subQ dara and 28-day induction cycles) went on to use dara + lenalidomide for all patients in the post-transplant maintenance set...
What factors do you use when considering the addition of celecoxib to adjuvant chemotherapy for patients with stage III colon cancer, given CALGB/SWOG 80702 trial results?
Based on the 80702 results, I have started checking for PI3K mutations. In patients with tumors that have a PI3K mutation, I especially recommend celecoxib or aspirin for secondary prevention. However, there are separate data that aspirin may be helpful for primary prevention of polyp formation. Thu...