Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the role of adjuvant radiation in R0 node positive resected pancreatic adenocarcinoma in light of the recently presented RTOG 0848 abstract?
There are three options here in my practice. 1) Treat, 2) don't treat, and 3) "watch and wait, then ablate" (for a local recurrence). In general, I treat patients with CXRT who have positive margins (IMRT 45 Gy/25# to regional volume with SIB of 62.5 Gy to the margin. If it is an R2 resection (which...
What adjuvant treatment approach would you recommend for a patient with early-stage MSI-high gastric cancer who received neoadjuvant ipilimumab (×2) and nivolumab (×6) per the NEONIPIGA regimen, followed by R0 resection with no pathologic response?
I would favor FOLFOX x6 as per classic. This scenario raises the question: Was this truly MSI-H? I would confirm MSI status with next-gen sequencing. I would have expected a response if MSIH on ngs with concomitant high TMB. Our institutional practice has been to review all MSI-H IHC cases done outs...
How would you manage endocrine therapy in a male patient with gBRCA2 with a metachronous contralateral ER+ breast CA that occurred while on adjuvant tamoxifen for a different ER+ breast CA?
This is a tough situation. There is very limited data on the risk of CBC in men with gBRCA2 pathogenic variants and its impact on survival. In general, men with breast cancer suffer a worse prognosis compared to their female counterparts, although a large part of this may be driven by late stage at ...
What treatment would you offer to a patient after resection of a solitary metastatic melanoma from the brain without evidence of other sites of disease?
Resected stage IV melanoma, including patients with resected brain metastases, was included in the CHECKMATE 238 study of adjuvant nivolumab vs. adjuvant ipi published by Weber et al in NEJM 2017, which was a positive study overall with improved RFS in the nivolumab arm. The magnitude of effect in t...
What systemic therapy, if any, would you recommend for a patient with oligometastatic melanoma who is rendered NED after resection?
This remains a very timely question and currently the data would allow for two options : observation vs adjuvant therapy with nivolumab.Observation is a very reasonable option since we know that this can result in prolonged overall and occasionally relapse-free survival in a subset of patients; howe...
Would you give adjuvant nivolumab for IIIA melanoma?
This is a very timely and excellent question. There have been recently three landmark adjuvant studies, and two recent FDA approvals that have changed our approach for patients with resected melanoma. All three studies were based on AJCC staging 7th edition and required patients to undergo complete ...
Do you consider tertiary grade pattern, LVI or PNI on prostatectomy specimens as adverse features to recommend EBRT and ADT for patients with unfavorable intermediate prostate CA after prostatectomy with undetectable PSA?
No, I don’t think there is any current available evidence to define a benefit for ADT in the post-operative setting for patients with an undetectable PSA. The two major trials which define a benefit for ADT in this setting, RTOG 9601 and GETUG AFU-16 had a lower limit of a PSA of 0.2 at treatment in...
How do you approach patients with stage III melanoma for adjuvant treatment?
Currently, there are FDA-approved adjuvant systemic therapy for stage III melanoma. These were based on the CheckMate 238 study (adjuvant nivolumab), KEYNOTE-054 (adjuvant pembrolizumab), and COMBI-AD study (adjuvant dabrafenib/trametinib). The KEYNOTE-054 compared adjuvant pembro vs placebo, with H...
What is your preferred first-line treatment for metastatic gastric adenocarcinoma that is PD-L1 CPS ≥ 10 and also HER2+?
Very recently, trastuzumab has been replaced in the first-line setting by the results of the HERIZON-GEA-01 study, which evaluated zanidatamab, a bispecific/biparatopic antibody against 2 epitopes of HER2. This study randomized patients to the control arm of trastuzumab/chemotherapy (Arm A) versus z...
Would you give chemotherapy and trastuzumab to a patient with multifocal high grade, microscopic (<5 mm) HR-, HER2+ IDC embedded in extensive DCIS, staged as pTis pT1a(m) N0?
The data is limited, especially in extensive high grade DCIS with microinvasion that is HER2 positive and the decision must build on the balance of benefit vs risk of treatment.In extensive DCIS with multifocal T1a as described in this question, I don't hesitate to recommend adjuvant chemotherapy wi...