Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you have indications for adjuvant radiation in H&N cancers (oropharynx, oral cavity etc.) other than listed in the NCCN guidelines (ECE, positive margins, pT3/4, N2/3 or Lv IV/V, PNI, LVSI)?
Yes
Does the EBCTCG meta-analysis showing higher LRR in NAC group sway you from giving neo-adjuvant chemotherapy to patients with localized breast cancer?
No. Neoadjuvant chemotherapy was not associated with worse distant recurrences or survival vs. adjuvant chemotherapy. The difference is likely due to more women undergoing breast conserving therapy (and in some cases no surgery in this metanalysis) after neoadjuvant therapy. We know that BCS will ha...
How would you treat an isolated lung recurrence from colon adenocarcinoma that was initially resected without adjuvant chemotherapy?
The data on the role of adjuvant chemo following pulmonary metastasectomy are of low quality, i.e. mostly retrospective small studies. One can find both arguments for and against adjuvant chemo.I would look carefully at the time elapsed from the resection of the colon cancer and the appearance of t...
Would you consider use of single-agent lenvatinib for advanced renal cell cancer after first-line therapy?
I have not used this combination because I feel more data is needed. Previous mTOR+VEGF combinations failed to improve outcomes when studied in large phase 3 trials, so I am a bit skeptical of these results and waiting for the phase 3 to ready out. In addition, there is significant toxicity wtih thi...
What is your preferred regimen for triple positive breast cancer with visceral metastasis while on adjuvant AI?
My preferred regimen in this clinical situation would be to start with a taxane-based regimen plus trastuzumab and pertuzumab, per the CLEOPATRA trial. In this study, there is a highly significant and clinically meaningful overall survival advantage to adding pertuzumab in patients with newly metast...
What is your preferred first line approach to patients with good PS stage IV non-squamous NSCLC that is EGFR/ROS1/ALK/BRAF WT and PDL-1 < 1%?
At least two phase III studies have now demonstrated the benefit of chemoimmunotherapy as first line therapy. The carboplatin/pemetrexed/pembroluzimab regimen, initially reported and FDA approved on the basis of a randomized phase II study has now been validated in the phase III setting (Keynote 189...
Among the many assays/tests available for "liquid biopsies" in metastatic NSCLC, are there any situations where you would want to use one specific assay over the others?
There are many commercial and academic assays under development. None are approved at the moment and none have been shown to be superior. Use of a well reported commercial assay with whom your institution has experience is reasonable
How do you approach colon cancer chemotherapy in a patient who has had documented coronary vasospasm with FOLFOX?
Although there are case reports of successful rechallenging with infusional 5-FU in the setting of calcium channel blocker treatment, I don't endorse this approach given the potential cardiac consequences. Capecitabine is not an appropriate alternative since it's just infusional 5-FU in a different ...
How do you approach small lymphocytic lymphoma that does not have a leukemic phase?
Patients with SLL very often (90-95%) have circulating tumor cells in the blood that are CD19, CD20, CD5, CD23, sig dim by flow consistent with CLL tumor cells. If not in the blood, these same cells evevn more often can be found in the bone marrow. If disease is in either site with nodal involvement...
What would you choose as a first line therapy for a patient with CLL who is asymptomatic with Rai Stage 4 with bulky adenopathy and organomegaly?
A big discriminating feature here would be based upon age. For a patient who is fit and <65-70 years, IGHV mutated disease may be curable with fludarabine, cyclophosphamde, and rituximab therapy, first piloted by Michael Keating's group at MD Anderson Cancer Center. At a median follow up time period...