Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider pembrolizumab for a patient with microsatellite stable stage IV colon cancer with high TMB on liquid biopsy who has progressed on all standard therapies?
The Keynote 158 study demonstrated an objective response rate of 29% in patients with MSS tumors and TMB >=10 mut/MB (Marabelle et al., PMID 32919526). FDA subsequently approved pembrolizumab treatment for patients unresectable or metastatic tumor mutational burden–high (TMB-H; ≥ 10 mutations/megaba...
How do you decide on the timing of neoadjuvant chemoRT or short course radiation for a patient with mid-upper rectal cancer with resectable liver only metastases?
Upfront multiD discussion is really essential for a case like this as I do think we need to be selective of ideal candidates. If the group consensus is to proceed along a pathway involving “curative intent” local therapies, I do favor starting with systemic therapy to establish disease biology/pheno...
Do you include bevacizumab with chemotherapy in patients with metastatic colon cancer with an intact primary tumor who have intermittent obstructive symptoms?
I agree with Dr. @Dr. First Last. If I am worried that obstruction could happen but we are not at the point where we need to pause for a diversion, I will start chemo without bevacizumab for the first 2 to 3 doses - so that we get that response that he mentions - and then I can add without being too...
How do you decide between CPX-351 and HMA + Venetoclax in treating transplant eligible AML-MRC?
I would consider CPX-351 (liposomal daunorubicin and cytarabine) in anyone who you would consider to be an induction chemotherapy (7+3) candidate. The indication is for newly diagnosed MDS/AML (AML-MRC) or treatment related MN (t-AML). Benefit is the response can be seen quicker in 1 cycle as oppose...
What is your approach to patients with malignant breast adenomyoepithelioma?
We recently published a case series and review for ADME breast tumors. (Parikh et al., PMID 33607537) No proven role for specific therapies but for malignant ADME over 2cm, there are cases of metastatic spread to lungs and brain. So we have discussed adjuvant chemo and/or endocrine therapy after com...
What is your preferred first line regimen for a patient with BRCA+ metastatic pancreatic cancer with poor performance status?
The key question here is, "Are there any data to support the use of maintenance olaparib in BRCA-mutated patients after non-cisplatin first line chemotherapy?" This question arises from the results of the POLO trial which showed improvement in progression-free survival with the use of maintenance ol...
Are there any clinical scenarios where you would recommend adjuvant docetaxel for localized prostate cancer?
This is quite a controversial topic and good for a tumor board discussion! The RTOG 0521 trial is the only trial to demonstrate a potential survival benefit with docetaxel in the adjuvant setting following radiation and in the setting of long term ADT. The absolute difference in OS at 4 years was 4%...
Would you modify your initial treatment for a patient with de novo metastatic HR- HER2+ breast CA who has cardiomyopathy at baseline (EF < 35)?
Fortunately, the incidence of cardiotoxicity with the combination of a taxane, trastuzumab, and pertuzumab is very low, and thus I would be comfortable starting with this treatment (preferably with weekly paclitaxel) and monitoring her with periodic echocardiograms (every 4-6 cycles, in the absence ...
Should patients receive thrombophilia testing in the setting of a provoked VTE secondary to hormonal therapy/OCPs?
Given that oral contraceptives are considered a provoking event (Ortel et al., PMID 33007077), ASH Choosing Wisely guidelines recommend against thrombophilia testing since the recommended duration of anticoagulation is only 3 months. (Hicks et al., PMID 24307720 & Hicks et al., PMID 25472968).
Is there a role for adjuvant systemic therapy (in addition to adjuvant radiation) in an early-stage, resected cutaneous angiosarcoma of the head/neck?
Angiosarcomas have a high rate of local (or distant) recurrence, but with all tumor resected and if there were wide surgical margins then radiation may be sufficient for a small superficial tumor, followed by close surveillance. If there is a recurrence, then our practice is to give neoadjuvant chem...