Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When patients with EGFR-mutant or ALK-translocated advanced NSCLC progress after all available targeted therapies, do you use chemotherapy or PD-1/PD-L1 inhibitor therapy as the next line?
In general I favor chemotherapy or a clinical trial for patients with sensitizing EGFR mutations after they have exhausted available EGFR TKI therapy. The EGFR mutated subgroups in both the nivolumab second line registration trials and the pembrolizumab second line registration trial trended toward ...
How do you approach first line therapy for metastatic, hormone receptor positive, HER2 negative breast cancer in post menopausal women?
I use palbociclib and letrozle in the vast majority of women who come to me with de novo ER positive MBC. If a woman recurs with ER positive MBC while on an AI, I use faslodex and palbociclib. Ribociclib also has shown benefit in the recently completed phase III (MONALESSA2) trial, but it is not yet...
Do you consider use of TIP as first-line therapy for poor-risk advanced germ cell tumors?
Unequivocally no. TIP seems clearly more toxic and achieves results no different than VIP or BEP given at high volume centers. TIP will not ever be compared to either and is going nowhere. In my view and the view of other testis cancer experts, the most important aspect is that these uncommon patien...
How do you treat fit patients with metastatic adenocarcinoma of colon who have progressed on at least 2 prior lines of standard chemotherapy?
The answer to this question depends on the patient's molecular diagnostics and prior therapy. I'll assume FOLFOX/XELOX-bev. If KRAS WT, I'll assume followed by FOLFIRI-EGFRi. If the patient is MSI-H, I would strongly recommend immunotherapy with pembrolizumab based on Le et al, NEJM. If MSS and you ...
How do you approach treatment options for men with germ cell tumors that relapse within 2 years of initial chemotherapy?
In general, patients who relapse more than 3 months out from initial chemotherapy will respond to platinum-based chemotherapy. I prefer TIP regimens x 2 followed by tandem transplant vs TIP x 4 but I will do the latter in patients who do not get approved for transplant or who are not medically clear...
Could a non-cirrhotic patient with a single HCC lesion measuring >5cm who is ineligible for liver transplant by Milan size criteria alone become a candidate if the tumor shrinks after TACE?
While the Mazzaferro (Milan) criteria still represent the primary basis by which HCC candidates for liver transplant are chosen, certain centers such as ours (UCSF) have studied the strategy of expanding eligibility criteria for OLT. This includes both increasing upper tumor size limits, as well as ...
Do you counsel patients on the risk of dementia following androgen deprivation therapy for prostate cancer?
No, I generally do not counsel men about this risk. The two studies from the same investigator use a data warehouse search algorithm that may not be accurate enough to fully characterize who gets Alzheimer's disease or may not be able to correct for confounding factors that may be different between ...
How to you treat patients with germ cell tumors that progress during treatment with first-line platinum-based chemotherapy (i.e. platinum-refractory disease)?
This is extremely uncommon and a common mistake is to label someone as cisplatin refractory who really isn't. I would have to see the pattern of markers over the course of treatment and be assured that sanctuary sites have been ruled out prior to formally declaring someone as cisplatin refractory. T...
How would you treat a patient with metastatic, MSI high, small bowel adenocarcinoma in the frontline setting and after first progression?
This is a really interesting question. If you prefer a more standard approach, I would recommend FOLFOX (I have used bevacizumab in some patients with this cancer, but there isn't great evidence I know of to support use). However, in an MSI-H patient, trying anti-PD-1 therapy sooner rather than late...
How would you treat a patient with metastatic colon adenocarcinoma with a HER2+ tumor who has progressed despite standard 5-FU containing regimens?
Assuming the patient has progressed on standard treatments for mCRC including oxaliplatin and irinotecan-containing regimens with the appropriate biologics, I would consider HER2 directed therapy. I generally prefer that to be on clinical trials such as MyPathway or MATCH or similar trials. Outside ...