Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What do you do for patients with HR+ inflammatory breast cancer who do not achieve a pCR with neoadjuvant chemotherapy?
I assume the patient in this question is HER2 negative. Inflammatory breast cancer is rarely HR+, HER2-, but for HR+ HER2- invasive breast cancer who do not achieve pCR with neoadjuvant chemotherapy, I would recommend to maximize the benefit of adjuvant hormone therapy.The patient certainly could jo...
How would you approach patients with ALK-positive metastatic NSCLC who progress on crizotinib and subsequently alectinib?
Ideally, I would biopsy the recurrence to determine if there is a defined resistance mutation that might be targetable by brigatinib or lorlatinib. I always try to maintain TKIs as long as possible. Dose escalation might be effective, but would not be my first choice. If none of these are options, r...
How do you approach adjuvant therapy in patients who have a poor clinical response to neoadjuvant endocrine therapy?
Clinical response rates to neoadjuvant endocrine therapy vary from 40-60% in ER-enriched tumors. Pre and post-treatment PEPI score is shown to be prognostic. It is currently unknown what is best to do for women who do not respond well clinically, or for those who have a high ki67 and/or high PEPI sc...
How would you treat a patient with high-volume metastatic prostate cancer who has asymptomatic biochemical relapse after having a good response to upfront docetaxel?
If the patient is asymptomatic or minimally symptomatic and now castrate-resistant, I would start with sipuleucel-T. Based on the PSA quartile data (Schellhammer et al 2013) and in line with current NCCN guidelines and supportive clinical and preclinical data, immunotherapy should be used as early a...
How would you approach a patient with smoldering myeloma that has a quickly rising and very high M-spike (6 g/dL range)?
The level is very high and worrisome for tumor lysis syndrome and cytokines related symptoms. I would do a bone marrow biopsy first and check free light chain assay. This may confirm the diagnosis of symptomatic myeloma. Also bone imaging study to find any lesions. Once you decide to treat I would ...
Do we have any data on sequencing of up front therapies for patients with high PD-L1 and targeted mutations?
Patients with EGFR and BRAF mutations or ALK and ROS1 fusions should receive 1st line approved TKI therapy and second line approved TKI therapy for EGFR and ALK. Checkpoint inhibitors should be used only after TKIs even if PD-L1 expression is high. For patients with PD-L1 expression >50%, it is not ...
Would you ever recommend resection only (no chemorads) for a T1N0 anal canal cancer?
Concurrent chemoradiation for SCC of the anal canal was first investigated in the preoperative setting to reduce the rate of recurrence after APR. This ultimately led to the realization that the vast majority of patients could be cured with chemoradiation alone. Since resection in this case necessit...
How do you approach previously treated grade 1 follicular lymphoma now with transformation to a large cell lymphoma?
I believe the question is an important one that has not been addressed by an adequately powered prospective study. These patients are often folded into studies of relapsed and refractory disease. The consensus is that these patients have a poorer prognosis than those with de novo diffuse large B-cel...
Would you use Ibrutinib plus Venetoclax as second line therapy in relapsed/refractory mantle cell lymphoma?
I may consider this for the right patient with Mantle cell lymphoma that has relapsed with TP53 and high risk prognostic score. Even though the data is very exciting it is a single arm study with a small patient cohort, I would want to see a randomized data to make a definitive switch. The CR rates ...
How do you manage patients with locoregional lymph node recurrence after radical cystectomy for muscle invasive bladder cancer?
Recurrent bladder cancer is typically a systemic disease. I would start with cisplatin based chemotherapy first and then add consolidative radiotherapy. There is a small body of literature on surgical consolidation as well. In our single instiution experience patients did very well following radioth...