Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How soon after surgery do you start chemotherapy for extensive stage SCLC following resection of a brain metastasis?
I believe chemotherapy is the backbone of therapy for small cell lung cancer. If a patient has asymptomatic brain metastases, I start with chemotherapy (or chemoimmunotherapy) alone and follow with repeat brain imaging. I will treat with RT after initial 4 cycles of chemotherapy if brain disease is ...
For a patient with isolated CNS recurrence of HR+HER2+ breast cancer after completion of adjuvant therapy, what, if any, systemic therapy would you start after completion of local therapy?
It is important to maintain curative intent in this situation. Most typically, patients with ER+/HER2+ (or triple positive breast cancer) are the youngest of all patients with ER+ breast cancer (Alqaisi et al BCRT 2014), and while anti-HER2 therapy is key, it is also critical to emphasize the role o...
How would you approach therapy for a young, fit patient with alveolar rhabdomyosarcoma involving the anterior nasal vault/sinuses in the absence of available clinical trials?
The patient should be risk stratified (as per the Intergroup Rhabdomyosarcoma Study Group classifications) and treated with multimodality therapy, including chemotherapy and likely definitive radiotherapy, depending on the specific location. Surgery is also a consideration, but these are generally c...
Would you assume a diagnosis of metastatic recurrence and initiate therapy for a patient with history of locally advanced NSCLC treated with definitive chemoradiation who develops multiple enlarging lung nodules that are too small to biopsy?
I don't believe that I can point to a study that will answer this question, so will revert to oncologic principles 101, namely that absent exceptional circumstances, we ought to biopsy first recurrence. In the question posed, that is following definitive (curative intent) chemoradiation (and now in ...
Are you recommending aspirin in breast cancer survivors?
I do not recommend aspirin in breast cancer survivors routinely. The role of aspirin in terms of improving survival is not clear yet- with some observational studies showing a benefit but no prospective high level evidence. There are a couple of large studies looking at this. There are various intri...
Would you consider nivolumab and ipilimumab as first line for pleural mesothelioma?
I found the overall survival benefit of Checkmate 743 presented at the WLCL presentation compelling. This is the most significant phase III data we have had and I was particularly encouraged by the sarcomatoid subset - traditionally much harder to treat - seeming to benefit at least the same if not ...
How do you approach the treatment of patients with an e14a3 (b3a3) BCR-ABL fusion in chronic phase CML?
The treatment is the same; the problem is how to monitor response as this rearrangement is detectable reliably by FISH and not by the typical RT-PCR. There is a report showing that CML with some rare fusion genes have a rapid response at early time points (3 and 6 months), but long term outcome seem...
How would you manage a patient who develops pleural and skin metastases shortly after completing neoadjuvant ddAC-T and surgery for a locally advanced triple negative breast cancer?
Any solid tumor refractory to frontline chemotherapy has three pathways moving forward:1. Clinical trial2. NGS on tissue to identify FDA approved targets (specifically BRCA in this case)3. Standard second line therapies.Under option 3: For PD-L1 > or = 1%, the combination of atezolizumab and nab-pac...
Can fulvestrant cause a tumor flare reaction in hormone receptor positive breast cancer?
No. Fulvestrant does not have agonist activity on the estrogen receptor, so it will not cause a true tumor flare. When it is paired with an LHRH agonist for a premenopausal woman, the LHRH agonist can cause an initial tumor flare because of the rise in estradiol before full ovarian suppression kicks...
How would you approach systemic therapy for a postmenopausal female with metastatic ER+/HER2+ breast cancer (liver/bone) who achieved a CR for 5 years on trastuzumab/pertuzumab and exemestane, with continued asymptomatic brain progression?
Switch to tucatanib, capecitabine, and trastuzumab. Consider returning to trastuzumab/pertuzumab based treatment at future systemic progression since currently there's no systemic progression. Consider continuing exemestane. This could be based on recent NSABP trials showing no detriment to concomit...