Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any role for the use of cytochrome P450 2D6 (CYP2D6) testing for tamoxifen resistance in routine practice?
This is a matter of some debate. The earlier retrospective studies did show some lack of tamoxifen benefit with certain homozygous genotypes of CYP2D6, but some later, larger trials did not bear this out. Thus, the matter remains unsettled in my opinion.
In newly diagnosed metastatic non-squamous NSCLC patients, which (if any) genomic targets are you routinely testing for besides EGFR and ALK?
If KRAS, EGFR, and ALK are negative, I also evaluate tumors for ROS1 (with crizotinib now approved for this indication), MET (exon 14 skipping or amplification), HER2, BRAF V600E, RET and NTRK (mainly for clinical trial options). This is usually part of a panel of 200 or so genes. While I try to exc...
Are you routinely offering nivolumab for second-line treatment of small cell lung cancer?
What is your approach to an optimally debulked patient with Stage Ia FIGO gr 3 serous carcinoma of the ovary?
For high grade serous early stage tumors, I use 6 cycles of carboplatin/paclitaxel. This is based on data from GOG 157 (Chan et al, Gyn Onc 2010). Single agent carbo would not be standard, but can be used in elderly or frail patients. This is a complicated situation, and treatment recommendations sh...
How do you approach systemic therapy for locoregional recurrence in a patient with triple negative breast cancer who has previously received anthracycline and taxane based chemotherapy?
The CALOR trial took a pragmatic approach and randomized patients to systemic therapy or not. A specific regimen wasn't specified. If the patient has a known BRCA mutation, I would extrapolate from the first line metastatic setting and use a single agent platinum. Outside of that unique situation, t...
When treating patients with immune checkpoint inhibitors, do you routinely check markers of endocrinopathies such as TSH/ACTH, or only when a patient has symptoms?
There are clearly defined parameters for routine monitoring that are outlined in the NCCN guidelines. We have incorporated these into our treatment plans. https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf
Do you omit adjuvant radiotherapy in T4a laryngeal SCC with favorable prognostic factors?
I guess one could omit PORT for such a situation. I have never encountered this situation and I don't know what data NCCN is using to support this recommendation. Historically, pT4 is the indication for PORT.
How does a finding of low level microsatellite instability (MSI-low) in colorectal cancer change your management?
I currently treat MSI-low the same as MMS, regardless of whether the treatment is in the adjuvant or metastatic setting.
Do you routinely use PET/CT to monitor response to systemic therapies in metastatic breast cancer?
This is an interesting question. I think a lot of us use systemic CT or PET-CT scanning at 3-4 month intervals to screen for progression in MBC while someone is on a therapy. Many of us do this even in bone only disease, looking for new metastases in visceral sites. There is a recent JCO publication...
For a patient with stage III NSCLC who is treated with chemoradiation followed by surgery, when do you offer additional "adjuvant" chemotherapy after surgery?
Several recent trials have addressed management of stage III NSCLC. The intergroup 0139 trial and the EORTC 08941 trial were prospective studies of patients with known mediastinal involvement comparing chemoradiotherapy with or without surgery. Neither prospective trial showed a survival benefit for...