Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you ever stop pertuzumab for stable disease in a patient with metastatic, HER2 positive breast with stable disease?
I would only stop pertuzumab if there is considerable toxicity (rashes, diarrhea, severe infusion reactions, etc). Given the substantial overall survival benefit seen in the CLEOPATRA study, I make every effort to continue both trastuzumab and pertuzumab in patients with metastatic HER2+ breast canc...
Are there any data to guide choice of immunotherapy agent in first line treatment for extensive stage small cell lung cancer?
Both the addition of durvalumab and atezolizumab to platinum etoposide resulted in a modest improvement in median progression free, overall survival and saw twelve-month overall survival rates just above 50%. The ECOG-ACRIN phase II trial of nivolumab added to platinum etoposide also improved PFS an...
How would you approach a postmenopausal patient with HR-,HER2+ breast cancer who has oligometastatic disease, and is s/p complete resection of brain met with no other evidence of systemic disease?
For local control, I would do stereotactic radiosurgery to the resection cavity. This is in line with NCCN guidelines and randomized trials, such as N107C, that show excellent local control with similar survival and better QOL compared to whole brain radiation.I would also recheck markers on the bra...
Would you consider neoadjuvant ifosfamide-based chemotherapy for a large (>10cm) high grade soft tissue extremity sarcoma in an attempt to achieve limb sparing surgery in an otherwise healthy young patient?
This question is similar to one previously posted:Are there any types of sarcomas that you use induction and/or concurrent chemotherapy with radiation prior to surgery?In cancers where chemotherapy confers a survival benefit (e.g. breast, osteosarcoma), chemo before or after surgery is fine. I would...
How do you manage oxaliplatin-induced acute peripheral nerve hyperexcitability?
This can be very frustrating for both the patient and the treating physician, as there is little that we can do to prevent this from happening. I have found that assurance is the most important thing that we can do for patients. For example, some patients can develop pharyngolaryngeal dysesthesias (...
How do you manage patients with pancreatic adenocarcinoma who progress during neoadjuvant FOLFIRINOX, such that borderline resectable disease is now unresectable but still localized?
Great question; this area is rapidly evolving. I hope some of the ViewRay crowd will see this and chime in. We give ablative doses of radiation (~100Gy BED). That results in survival that is similar to surgery in patients like this (inoperable in an aggressive surgery practice at MSKCC, MSS in prepa...
Would you consider adding Enasidinib to frontline combination therapy with HMA and Venetoclax in a patient with newly diagnosed AML with IDH2 mutation that is >75 or unfit for standard induction therapy?
This question raises an important treatment consideration, but I would probably not use triple agents at this stage given lack of maturity of clinical trials. Venetoclax has been quite effective in those who have IDH1 and IDH2 mutations (Chan SM et al Nat Med 2015; 21:178), so I would probably start...
How do you manage immunotherapy-associated pruritis that is persistent despite steroid use?
For pruritus managment, I consider the use of gabapetin, and if refractory to steroids and gabapetin, I consider aprepitant or omalzumab (consider measuring IgE levels), and refer the patient to dermatology for their input.
How do you approach treatment of locoregional squamous cell carcinoma of the stomach extending to GE junction?
Squamous cell carcinomas of the stomach are very rare. There are some published case reports for SCC of the stomach in the metastatic setting. Unfortunately, there are not many series describing the approach for locoregional disease. I have recommended the same approach used for adenocarcinoma which...
Are there any safety or efficacy data regarding the use of EGFR inhibitors in patients on hemodialysis for ESRD?
It's limited. Erlotinib is metabolized in the liver and pharmacokinetic data in patients on hemodialysis is similar to those with normal function. This was reported in a 3 patient case series (Togashi et al, JTO 2010). Appears comparable with osimertinib as well. A case report (Tamura et al, Lung Ca...