Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you add a PARP inhibitor to bevacizumab maintenance for a patient with a high grade serous ovarian cancer with a germline BRCA2 variant of unknown significance and negative somatic testing?
The information above is insufficient in informing a treatment recommendation. As defined, the implications of the BRCA2 VUS are unclear. In this setting, I would advocate that HRD testing be performed on the tumor tissue. If the tumor is HRD+, I would certainly counsel the patient on the utility of...
What regimen would you offer a young patient with T-cell ALL who recurred a short time after allo-transplant and was initially treated with CALGB10403?
The answer is always clinical trial if feasible. If only commercial options: Assuming morphologic relapse, I tend to favor peg-asp containing regimen if the patient is fit enough to receive – especially if ETP variant. I like SMILE, but important to stress that regimen may come with considerable mye...
What is your preferred regimen for metastatic clear cell RCC following progression on IO/TKI?
Patients with progression after IO-based therapies are increasingly common. Standard options include single agent TKI (cabozantinib most commonly used after axi/pembro) and lenvatinib/everolimus. The role of additional IO-based therapy in this setting is unproven, although there are data with lenvat...
What treatment options would you provide a HER2+/HR+ patient with significant residual disease s/p TCHP if they go on to develop severe neuropathy following adjuvant T-DM1 therapy?
We know from the KATHERINE study that invasive disease or death had occurred in 12.6% of the T-DM1 group and in 22.2% of the trastuzumab group. The estimated percentage of patients who were free of invasive disease at 3 years was 88.3% in the T-DM1 group and 77.0% in the trastuzumab group. However, ...
How do you counsel patients referred for abnormal light chain ratio when individual light chains are in normal range?
It appears you are referring to a situation where the uninvolved light chain is quite suppressed and the potentially involved light chain is normal, generating an abnormal ratio. There are other situations such as in CKD where both kappa and lambda light chains will be elevated but the ratio will be...
How would you approach low grade non-invasive urothelial carcinoma arising from seminal vesicle and ejaculatory ducts with invasion into prostate?
Primary urothelial carcinoma of seminal vesicle is extremely rare. There is some skepticism whether this is a true entity. More common is the secondary spread from bladder primary. This can happen as a result of direct invasion through bladder wall or via mucosal spread. Formal is staged as T4 disea...
For patients with metastatic triple negative breast cancer on nab-paclitaxel + atezolizumab who have an ongoing response, are you continuing immunotherapy after the FDA withdrawal of atezolizumab?
Yes, I would consider continuing immunotherapy. We know that the full benefit of immune checkpoint inhibitors may be delayed and may be durable as opposed to single agent chemotherapy. Even in patients with an early response to atezo and nab-paclitaxel, I would continue the combination if possible, ...
Would you consider switching endocrine therapies for a peri-menopausal woman on adjuvant tamoxifen solely due to an estradiol level if this was checked and found to be significantly elevated?
I agree with Dr. @Dr. First Last that this is likely ovarian hyperstimulation from tamoxifen which can occur in 9-17% of women and is more likely to occur in younger women treated with tamoxifen therapy alone. In one study, a level of over 300pg/mL and follicular diameter over 30mm were used to defi...
What is your approach to the treatment of metastatic renal cell carcinoma with unclassified histology?
The key to managing unclassified renal cell carcinoma is to obtain a detailed histological and molecular characterization. Clarify with pathologist(s) regarding unclassified nature - are there some features characterizing the tumor as being of a recognizable subtype? Next generation sequencing to de...
How do you approach staging and treatment for a p16+ nasopharyngeal SCC?
First question is whether it is strictly p16 positive and confirmed EBER ISH negative. If so, I treat it like p16 positive oropharyngeal cancer with chemoradiation. I don't give adjuvant chemo. All the adjuvant chemo or induction chemo data is for EBER ISH positive nasopharyngeal carcinoma.