Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you use alternative management in a chronic phase CML with a 3 way translocation between chromosome 9, 22 and 7?
Variant Philadelphia chromosome translocations that involve a third or fourth chromosome in addition to chromosomes 9 and 22 are seen in around 5% of patients with CML. They are considered simple translocations if involved chromosome 22 in addition to a chromosome other than 9, or complex if involve...
In what situations do you obtain both a pelvic MRI and EUS for rectal cancer staging and treatment planning?
I'm not sure that T2N1 is boderline - preop CRT is still a standard of care for node positive disease. Generally, thin slice (3mm or less) MRI with external (if available) or internal coil is the preferred staging modality for patients with newly diagnosed rectal cancer. Utilize the T2 images and c...
What is the optimal management of Krukenberg tumor in a pre-menopausal woman with HR pos metastatic breast cancer, progressed on Tamoxifen and second line Gemcitabine, with the rest of the disease sites well controlled?
If the Krukenberg tumor is the only site of metastasis or active disease in a premenopausal patient with HR+ metastatic breast cancer, I will recommend a complete surgical resection of the tumor together with B/L oophorectomy to render her surgical menopausal. There is no definite data to show surv...
Do you have indications for adjuvant radiation in H&N cancers (oropharynx, oral cavity etc.) other than listed in the NCCN guidelines (ECE, positive margins, pT3/4, N2/3 or Lv IV/V, PNI, LVSI)?
Yes
Does the EBCTCG meta-analysis showing higher LRR in NAC group sway you from giving neo-adjuvant chemotherapy to patients with localized breast cancer?
No. Neoadjuvant chemotherapy was not associated with worse distant recurrences or survival vs. adjuvant chemotherapy. The difference is likely due to more women undergoing breast conserving therapy (and in some cases no surgery in this metanalysis) after neoadjuvant therapy. We know that BCS will ha...
How would you treat an isolated lung recurrence from colon adenocarcinoma that was initially resected without adjuvant chemotherapy?
The data on the role of adjuvant chemo following pulmonary metastasectomy are of low quality, i.e. mostly retrospective small studies. One can find both arguments for and against adjuvant chemo.I would look carefully at the time elapsed from the resection of the colon cancer and the appearance of t...
Would you recommend RNI for a triple negative cancer s/p lumpectomy and ALND with low LN positivity rate?
My current practice is to offer patients with triple negative disease and positive nodes after ALND RNI with their whole breast irradiation. MA20 included such patients with roughly 85% having 1-3 LN+ and more than 65% had 10+ LN removed. The addition of RNI increased survival in ER- patients (81 vs...
Would you consider use of single-agent lenvatinib for advanced renal cell cancer after first-line therapy?
I have not used this combination because I feel more data is needed. Previous mTOR+VEGF combinations failed to improve outcomes when studied in large phase 3 trials, so I am a bit skeptical of these results and waiting for the phase 3 to ready out. In addition, there is significant toxicity wtih thi...
What is your preferred regimen for triple positive breast cancer with visceral metastasis while on adjuvant AI?
My preferred regimen in this clinical situation would be to start with a taxane-based regimen plus trastuzumab and pertuzumab, per the CLEOPATRA trial. In this study, there is a highly significant and clinically meaningful overall survival advantage to adding pertuzumab in patients with newly metast...
What is your preferred first line approach to patients with good PS stage IV non-squamous NSCLC that is EGFR/ROS1/ALK/BRAF WT and PDL-1 < 1%?
At least two phase III studies have now demonstrated the benefit of chemoimmunotherapy as first line therapy. The carboplatin/pemetrexed/pembroluzimab regimen, initially reported and FDA approved on the basis of a randomized phase II study has now been validated in the phase III setting (Keynote 189...