Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider PRRT re-treatment in a patient with a well differentiated NET previously treated with 4 cycles of PRRT?
Yes, but only for highly selected patients. Might consider discussing retreatment with PRRT (R-PRRT) in those who: 1. Derived good response (or prolonged stable disease) with prior PRRT and,2. Don't have better options available (for example, would not do R-PRRT before CapTem, afinitor, sutent in pN...
What first line treatment would you consider for a patient with stage IV gastric cancer that is HER2 negative and MSI-high?
For a patient with MSI-H, HER2 negative metastatic gastric cancer, PD1 blockade with pembrolizumab (pembro) would be my first choice. The KEYNOTE-062 data support the efficacy of pembro in this setting [Shitara et al., PMID 32880601].The phase 3 KEYNOTE-062 study randomized patients with untreated, ...
Would you give adjuvant therapy for a urothelial carcinoma T2 on TURBT but pTis at margins on cystectomy?
No, this patient would be followed by active surveillance based on NCCN guidelines, e.g. visits, labs, urine cytology, CT chest, CT IVP; would pay attention for any symptoms to upper tract and urethra that may trigger further evaluation. Would discuss with Urologist & Pathologist about the case, the...
Should patients with active multiple myeloma and other gammopathies be routinely vaccinated against herpes zoster?
All patients starting anti myeloma therapy should be on acyclovir prophylaxis, typically starting at 400 mg BID but renally adjusted to 400 mg daily if needed. This provides substantial protection against zoster. Patients may get shingrix but given that their immune response to the vaccine may be su...
What systemic therapy would you offer for a local, unresectable relapse of a mixed acinar neuroendocrine carcinoma of the pancreas?
This is a very interesting question. I agree with the overall discussion with some points that need to be clear: Did the pathology show mixed acinar and NEC with >30% of each component? or just acinar with NE features? I agree the data about MANEC is very limited and exclusively retrospective. What ...
For patients with triple negative breast cancer, currently undergoing neoadjuvant dd AC, would you consider adding pembrolizumab to weekly paclitaxel based on recent KEYNOTE-522 and continue as adjuvant?
I think the decision should be informed by the degree of response to AC and initial bulk of disease at presentation. In patients who complete the AC portion and still have clinical evidence of substantial residual disease, I would absolutely consider adding pembrolizumab and carboplatin to weekly pa...
Would you routinely use G-CSF prophylaxis in a CMML patient for decitabine-related neutropenia?
I would use G-CSF if the patient is in remission/responding to decitabine and neutropenia, is decitabine induced and not due to CMML. I will not use at diagnosis or when not in remission as neutropenia may be disease-related.
In patients who receive neoadjuvant pembrolizumab and chemotherapy for TNBC, how will you manage adjuvant treatment if they have a germline BRCA mutation?
For patients with clinically high risk early TNBC and germline PV in BRCA 1 or 2 undergoing neoadjuvant chemotherapy along with pembrolizumab, the course of adjuvant therapy will depend on pathologic response at surgery.For those with pCR - I would continue adjuvant pembrolizumab for patients who ar...
What is your preferred first-line therapy for metastatic extraskeletal osteosarcoma in a young, fit patient?
EOS behaves more like a soft-tissue sarcoma c.f. skeletal OS, so we treat with anthracycline plus Ifosfamide. Cisplatin and HD MTX routinely used for skeletal OS do not have significant activity in EOS.
Would you consider neoadjuvant chemoradiation with oral capecitabine for a locally advanced sigmoid adenocarcinoma 20 cm from the anal verge?
If the tumor is above the peritoneal reflection, and the patient has no metastatic disease, and the surgeon thinks a surgery with a negative margin is feasible, upfront surgery would be my choice followed by adjuvant chemo if appropriate.