Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What treatment would you offer for patients with metastatic NSCLC (adenocarcinoma) who are EGFR positive AND PD-L1 >50%, who fail first line EGFR therapy (and are negative for T790M mutation)?
There are many clinical trial approaches that are evaluating immunotherapy among patients with EGFR mutations. Yet, there is little data to date of large populations of patients with long lasting responses to single agent PD-1 or PD-L1 inhibitors in the setting of EGFR mutations. Outside of a clinic...
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
I do not offer consolidation chemotherapy to patients prior to durvalumab in patients with locally advanced, unresectable NSCLC. The PACIFIC trial was a randomized phase III trial that established the role of consolidation durvalumab after definitive chemoradiation for patients with stage III NSCLC....
When would you offer single fraction adjuvant partial breast irradiation instead of a 5-10 fraction course for early stage breast cancer?
We have not offered a single fraction, and our standard is 26 to 30 in 5 fractions. Data on a single fraction is not enough to support this recommendation for now.
Are Mammaprint and OncotypeDx as useful in stratifying risk in patients with early stage HR+, HER2 negative lobular carcinomas, as in those with ductal carcinomas?
OncotypDX is not very useful in stratifying patients with early stage HR+ HER 2 negative invasive lobular carcinoma. Several studies (MD Anderson, Penn State) have shown that only 1-2 % of invasive ILC cancers are classified as High risk therefore receiving strong recommendation for chemotherapy. Si...
Is there anything you use for patients with anticipatory nausea who has failed Ativan and Zyprexa?
I know of no data, but I would consider hypnosis, mediation and mindfulness, cognitive behavioral therapy, acupuncture, and medical marijuana as possible options for anticipatory nausea refractory to lorezapam and Zyprexa. Hypnosis, mindfulness, and cognitive behavioral therapy are in a sense are re...
What would be the next step if a patient’s serum testosterone remains above 40 several weeks after the initial dose of a GnRH agent in the treatment of prostate cancer?
Real-world data show that approximately 3-7% of patients experience breakthroughs above 40 ng/dL per patient course, while 6.6% experience breakthroughs above 32 ng/mL (1.1 nmol/L). When using the lower threshold of 20 ng/dL (0.7 nmol/L), breakthrough rates increase to approximately 41%. One large r...
For early-stage, HR+ Her2- breast cancers, when do you use OncotypeDx v. Mammaprint?
The reason to use any multiparameter assay is to determine which patients need chemo and which don't. To say that another way - it is about the predictive ability, not the prognostic ability. Until very recently, Mammaprint only had prognostic data so I always used Oncotype. The MINDACT trial recent...
How does genomic profiling/next-generation sequencing assays influence your treatment recommendations in metastatic breast cancer?
At the current time, there are no evidence-based, FDA-approved or NCCN-recommended uses of genomic or protein-based assays other than ER, PR, or HER as well as gene expression profiling results like the 21-gene/Oncotype or 70-gene MammaPrint assay for routine management of breast cancer. There is no...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...
How do you counsel patients on the risk of thromboembolic complications with use of immunotherapy in NSCLC?
Patients with metastatic lung cancer are at increased risk of thromboembolic events with an estimated frequency of 13.9% (Connolly et al., PMID 23026639). Preclinical data show that PD-1/PD-1 pathway blockade may lead to increased levels of pro-inflammatory cytokines and T cell driven progression an...