Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For lung cancer patients who experience grade 3/4 toxicity from a PD-1 inhibitor necessitating cessation of therapy, but whose tumor has responded to the treatment, do you consider restarting PD-1 inhibitor therapy at the time when they progress again?
This is a highly challenging question that all of us face now with increasing frequency given the ever-widening utilization of checkpoint inhibitors. A decision as to resuming an anti-PD-1/PD-L1 agent in a patient who suffered a serious immune-mediated side effect clearly requires great judgment and...
For the first-line treatment of metastatic lung adenocarcinoma without a targetable driver mutation, do you routinely add bevacizumab to the chemotherapy backbone in the absence of a contraindication to the drug?
That is a really good question. In my practice, I typically will use carboplatin plus pemetrexed for 4-6 cycles followed by maintenance pemetrexed. The addition of bevacizumab consistently improves response rates when added to chemotherapy, so if I have a patient that is symptomatic from local disea...
How do you treat patients with small cell lung cancer that is primarily refractory to platinum/etoposide (i.e. disease that continues to progress despite first-line chemotherapy?)
Unfortunately I have rarely seen second-line therapy provide meaningful benefit in patients with previously treated small cell lung cancer and have little enthusiasm for treating these patients outside of a clinical trial. Recently reported data for therapies such as nivolumab+Ipilimumab and rovalpi...
What adjuvant chemotherapy regimen is most appropriate for a patient with local recurrence several years after surgery and ddAC-T for localized breast cancer?
In this situation, it is preferable to use a chemotherapy regimen that has been shown to be effective in the adjuvant setting. For a patient who has already received ddAC-T, my choice would be TC (docetaxel/cyclophosphamide), or even CMF. The role of chemotherapy for locoregional recurrence is still...
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 ...