Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For ER+ breast cancers that are clinical Stage IIB (T2N1) nearing locally advanced stages, what criteria do you use to determine if you would offer neoadjuvant chemotherapy?
This is an interesting question. Assuming this is regarding ER positive but HER2 negative tumors, the factors I would consider that would favor the decision to use upfront chemotherapy are the following: 1. Tumors that are grade 3 or high Ki-67 2. Low ER positive tumors 3. Younger, premenopausal wom...
Would you recommend adjuvant chemotherapy therapy to a premenopausal patient with ER+ lobular breast cancer who had a partial response to neoadjuvant endocrine therapy?
One approach is if you have enough tissue from the diagnostic core biopsy to run an Oncotype then base your decision on adjuvant chemo from that. This is assuming you are confident she is a N1 case (no treatment effects noted in other nodes). There is an ASCO 2018 abstract from Mayo (Talal Hilal et ...
What is your approach to localized pancreatic cancer that would otherwise be resectable, except for poor patient characteristics?
Tough question—since there is no prospectively validated phase III data to guide us in such situations, we've adopted an approach that utilizes bi-modality treatment sequencing, punctuated with aggressive supportive care and frequent multidisciplinary evaluation (q 2 months) to re-assess eligibility...
How long would you continue second line maintenance PARP inhibitor in a patient with recurrent stage IV BRCA+ ovarian cancer who had CR and remains NED?
For patients with platinum-sensitive relapsed ovarian cancer with a partial or complete response to platinum-based chemotherapy, niraparib, olaparib, and rucaparib are approved by the FDA for maintenance therapy. While PFS outcomes are improved with these agents regardless of BRCA mutation status, t...
How do you decide between Nivolumab + Ipilimumab and Pembrolizumab or Nivolumab monotherapy in later lines of MSI-H Colorectal cancer?
The data are fairly clear that patients with the combination of nivolumab and ipilimumab is highly active based on the Checkmate-142 study (Overman, et al, JCO 36, no. 8 (March 10 2018): 773-779, 2018) showing a 55% RR with 5% CR (n=119 patients, all post at least 2 prior chemo regimens). PFS at 12 ...
What would you recommend as adjuvant treatment for a patient with Stage III melanoma?
Good question at just the right time. As of last week the treatment of stage III melanoma has dramatically changed based on 2 trials reported in the NEJM. The first trial in 906 patients demonstrating that nivolumab is superior to iplimumab with much less toxicity, was stopped early because of clear...
Would you recommend adjuvant nivolumab for patients with upper tract urothelial cancer?
For any patient with upper tract UC who is eligible for cisplatin, adjuvant cisplatin based chemotherapy would be the preferred standard of care approach. This would be supported by results from the POUT trial where patients treated with cisplatin were deprived significant DFS benefit compared to su...
Would you provide vitamin B12 supplementation to a patient on pemetrexed therapy if their B12 levels are normal or high?
Yes. B12 supplementation has been shown to decrease the risk of paresthesias.
Would you offer adjuvant chemotherapy for platinum eligible patients with pT2pN0 urothelial carcinoma of bladder or UTUC who did not receive neoadjuvant chemotherapy?
I agree with both of my colleagues that adjuvant cisplatin-based combination chemotherapy is unproven for pT2N0 bladder cancer, although the POUT upper tract urothelial carcinoma phase III trial (which demonstrated significantly improved DFS) did recruit >=pT2N0 patients to evaluate adjuvant gemcita...
Do you perform routine interval lung cancer screening in non-smokers who are 1st degree relatives of patients with non-smoking related lung cancers with known EGFR mutations?
I would not. Although there may be a measurable increase in the risk of lung cancer detected in population studies, the absolute risk is probably far below the equivalent of even a low-risk, current or former tobacco user. This is a hard conversation to have with people who believe their risk to be ...