Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a young patient with oligometastatic inflammatory triple negative breast cancer with bone only metastases?
There is no clinical trial data to provide solid guidance on how to manage oligometastatic de novo stage IV disease. We learned that surgery to the primary tumor without ablating distant mets and giving multidrug adjuvant-like systemic therapy does not improve survival. We also learned that SBRT to ...
When do you recommend incorporating HER2 testing into the diagnostic pathway for tumor types where HER2 overexpression is not commonly assessed?
I would recommend HER2 IHC testing at the time of advanced cancer diagnosis or at the next therapy change, whenever HER2-targeted therapy would be considered in the treatment course.
How would a low tumor mutational burden (<10) influence your decision to offer neoadjuvant immunotherapy for cutaneous squamous cell carcinoma?
TMB is not an accepted biomarker yet for predicting immunotherapy response in cSCC. If you want to use predictive molecular testing, you can consider using Tempus’s Immune Profile Score (IPS) offered as part of their NGS testing platform. The IPS score is based on a set of genes generated with an AI...
How frequently would you consider IV iron treatment for ongoing iron loss and severe iron deficiency anemia?
Absolutely. You first want to estimate and replace their iron deficit. For patients who are very anemic, they can start at 2-3 grams deficit. I usually don’t give more than 1500 g of iron dextran at one time, but I will have no concern about doing 1000 or 1500 mg weekly until I have replaced their d...
Does being on maintenance pembrolizumab change how you manage patients with partial metabolic response on PET/CT 3 months after chemoradiation for cervical cancer?
No, a good percentage of patients will not have a complete response by 3 months. Six months seems to be a reasonable cutoff. Persistent disease at 3 months does not seem to be a worse prognostic factor than completion at 6 months. At the 3-month mark, I would not manage differently. At 6 months, I w...
How would you approach treatment for a postmenopausal patient who was treated more than 5 years ago with AC-T for TNBC, and who now presents with ipsilateral, locally advanced, node-positive TNBC, but has severe residual neuropathy from prior taxane exposure?
Standard neoadjuvant chemotherapy for TNBC would have been anthracycline- and taxane-based regimens, with the addition of platinum agents (carboplatin or cisplatin) in high-risk cases to improve pathologic complete response (pCR) rates. However, in this case, further taxane use (including docetaxel)...
Are certain PD-L1 assays considered more accurate or reliable than others for NSCLC?
In the treatment of NSCLC, squamous or non-squamous, there are three potential checkpoint antibodies available (Nivolumab, Pembrolizumab and Atezolizumab), only one of which is tied to a companion diagnostic of PDL1 expression by IHC (Pembrolizumab) - though in both of the other antibodies, there is...
When treating stage IVB cervical cancer with both systemic chemotherapy and local pelvic radiation therapy, do you incorporate the use of bevacizumab as in GOG 240?
I generally favor starting with multi-agent systemic therapy (Carbo/Taxol/Avastin +/- Pembro) upfront to confirm that the patient is going to respond appropriately and not blossom with metastatic disease prior to making a decision of radiating the pelvis in oligometastatic cervical cancer, similar t...
Would you consider adjuvant olaparib in a patient with HER2+, high-risk, early stage breast cancer with germline BRCA mutation?
We do not yet know whether HER2 amplified cancers in women with BRCA mutations are in fact driven by HER2. However, given the remarkable efficacy of anti-HER2 therapy, I would be loath to discard the accepted strategies for managing HER2-positive disease. There is also a pragmatic challenge which is...
For a post-menopausal woman with a pT1c node negative HER2 positive breast cancer, does ER status influence your choice of adjuvant paclitaxel/trastuzumab versus docetaxel/carboplatin/trastuzumab?
Data from pivotal trials addressing adjuvant therapy options for HER2 positive cancers, like BCIRG 006 and APT, doesn't support treating ER positive, HER2 positive cancers any differently than ER negative, HER2 positive cancers.BCIRG 006 that showed TCH regimen to be as good as ACT-H (and superior t...