Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you omit anthracyclines in triple positive breast cancer?
The BCIRG 006 trial is relevant for all Her2 positive disease, both ER positive and ER negative. Depending on the risk profile of the patient (T2 disease and beyond), I give TCHP x 6 as neoadjuvant therapy per Neosphere and Tryphanema. For T1cN0 disease that is ER negative, I give adjuvant TH x 12, ...
What is your preferred front line regimen for metastatic squamous cell NSCLC that is PD-L1 and driver mutation negative?
I believe each are acceptable options. I have generally been using carboplatin and weekly paclitaxel fairly commonly. This regimen is based on Quoix, et al Lancet trial. This study was in elderly patients. I find this very well tolerated with low chances of cytopenias, alopecia. If I have concerns a...
Do you consider alternate therapy with a different anti-PD1 agent after a patient responds to an anti-CTLA4 +/- anti-PD1 agent but develops serious side effects?
The short answer is no. Pembro and Nivo are essentailly the same drug and in all the studies, once the patient has developed grade 3 toxicity the treatment is complete because further dosing will result in even more severe toxicty. The only exception is for endocrinopathies which can be managed with...
Are you ordering EGFR testing on all patients with NSCLC after complete resection in light of ADAURA?
Prior to FDA approval of adjuvant osimertinib, our team had not been ordering molecular diagnostics on people with stage I-III NSCLC as we viewed such testing as a poor use of medical and financial resources. About 70% of people with resected stage IA NSCLC will not recur, so there will never be a n...
How would you qualify and treat a patient with neutropenia, anemia, and abnormal NK cell population with normal trilineage marrow maturation?
I would run a molecular test to confirm that the clonality does not show a CD8-positive clone, as that is more common in LGL. The findings of a clonal NK population by flow cytometry would be enough, in the setting of neutropenia and anemia, to consider a diagnosis of NK cell LGL.
How do you choose between azacitidine and decitabine when deciding to treat a patient with MDS with a hypomethylating agent?
The only agent to prolong overall survival in patients with MDS is azacitidine so this is always my first choice particularly in older individuals at higher risk for complications of myelosuppression occurring at a higher rate with decitabine. Other issues to consider include ease of administration ...
Would you prescribe an aromatase inhibitor prophylactically for a post-menopausal woman with a deleterious BRCA2 mutation and a history of DCIS who declines prophylactic mastectomy?
The IBIS II trial (Lancet Onc Forbes et al 2016) established anastrazole was non inferior but not superior in preventing recurrences after DCIS. The MAP3 trial (Goss NEJM) demonstrated efficacy of extemestane vs tamoxifen in the chemoprevention of a first breast cancer in higher risk postmenopausal ...
When treating a patient with colon cancer with adjuvant FOLFOX, in what situation, if any, would you consider removing the 5-FU bolus empirically?
I'm not aware of any data that clearly indicate how much the 5-FU bolus really adds to the therapeutic efficacy of infusional 5-FU regimens. I think the benefit (if any) is likely to be very small. That being said, if I'm treating a patient with curative intent, I don't drop the 5-FU bolus unless co...
For localized esophageal cancer in patients with preexisting neuropathy, what do you use concurrently with radiation therapy?
I would probably start with low-dose carboplatin and paclitaxel as done in the CROSS trial, and monitor carefully for worsening neuropathy with weekly assessment. As the doses are low and the duration of therapy limited to only 5 weeks, we may not see much worsening. In CROSS, there was 15% neurotox...
Would you consider using Tamoxifen instead of an AI in a post-menopausal women with ER+ and/or PR+ breast cancer who can't/won't discontinue hormone replacement therapy?
I use tamoxifen in a switching strategy in many postmenopausal women anyway so the short answer is yes. The longer answer is that the ongoing use of HRT in this setting has issues that aren't solved by whether you use a SERM or an AI.