Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach the management of small, mutli-focal gastric NET?
Gastric carcinoid tumors are categorized into types 1, 2, or 3. Type 1 occurs in the setting of autoimmune atrophic gastritis. Type 2 is Zollinger Ellison syndrome. Type 3 is sporadic. I would recommend checking a gastrin level, B12, iron and ferritin. Endoscopic evaluation and mapping biopsies. Tre...
Given more restrictions on later line PARP inhibitor use for patients by BRCA status, would you consider repeat biopsy with somatic testing to identify candidates for second line maintenance therapy following platinum treatment for a patient who is gBRCAwt?
I would be comfortable deciding on the use of PARP maintenance in the second line based on initial somatic testing and would not feel a need to rebiopsy. Additionally, olaparib still has an indication for BRCAwt patients for maintenance post frontline regardless of biomarker status. Disclosure: No...
How do you manage a patient with gastric/GE junction carcinoma who has positive lymph nodes at resection after neoadjuvant chemotherapy?
So, we know from the review of the MAGIC study by Dr. Smyth that ypN+ tumors are associated with a worse prognosis than ypN0 tumors. However, there doesn't seem to be anything we can clearly do about it with standard options:1) Changing chemotherapy is not likely to be helpful. Phase III studies in ...
What is your preferred non-taxane chemotherapy regimen for early-stage HER2 negative breast cancer patients who develop grade 3/4 neuropathy before completion of taxane-based therapy?
Depends on the case since it is not clear why neoadjuvant TC was chosen. If she was ER-HER2- stage 2-3 usually AC-T is given so an anthracycline regimen would recommended (unless there is a cardiac concern in which case CMF may be considered). ER+HER2- disease may not need additional chemo and may b...
Would you consider a trial of pembrolizumab in a patient with metastatic urothelial carcinoma progressing on atezolizumab?
I dont think that would make sense. The monotherapy data for all the CPI are very similar. IMvigor 211 was a negative trial purely on a "trial design" issue. The ITT population was positive favoring atezolizumab over chemotherapy. I would consider a CPI after a trial of chemotherapy or radiation whi...
How are you incorporating abscopal radiation into your practice for metastatic NSCLC?
There is not enough evidence to guide our daily clinical practice about radiation abscopal effect off protocol. However, in stage IV NSCLC, we can use RT to: 1. Eliminate/control chemo or target therapy resistant or persistent primary and oligo-metastases 2. Concurrent SABR with targeted therapy for...
How do you decide on the optimal neoadjuvant regimen for locally advanced GEJ cancer?
There is no randomized trial comparing the neoadjuvant chemo (MRC OEO2 or OEO5 trials) and neoadjuvant chemoradiation (CROSS trial) approaches in this setting. That being said, it's clear that chemoradiation produces more pathologic complete responses. Non-randomized data from MD Anderson (Swisher e...
Is there a role for trastuzumab in the preoperative chemoradiation regimen for HER2 + esophageal adenocarcinoma (cT3N0)?
Outside of a clinical trial, I would not add trastuzumab to neoadjuvant chemoradiation at this point. RTOG 1010 will shed light on the utility of trastuzumab in this setting.
In a patient with resected NSCLC whose only site of relapse is CNS (treated with WBRT or SBRT), would you also start systemic therapy with erlotinib/afatinib if the patient was found to be EGFR positive?
Would not do WBRT. if there are more than a dozen would treat with osimertinib as it crosses the BBB. If there were just a few and PET negative would trreat with SBRT and follow with ctDNA, brain MR and chest CT
Based on the FLAURA trial, would you consider using osimertinib firstline in EGFR-mutated NSCLC?
Yes I would. The primary reasons are that the drug is not only has better PFS but also is better tolerated and has CNS activity. There remain several questions, 1. What therapy to choose in patients who progress after front line osimertinib? 2. Does the drug only work in the 50-60% of the patients w...