Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the role of neo-adjuvant chemotherapy in triple positive cT1c N0 breast cancer especially after recent data from KATHERINE trial?
This is an interesting issue, and one discussed by Dan Hayes in his NEJM editorial accompanying the KATHERINE publication.T1cN0 triple positive disease in the original trial of adjuvant paclitaxel/traztuzumab x 12 weeks (Tolaney, NEJM 2016) had a 4 year EFS in excess of 97%. Therefore I am not sure ...
Would you switch to TDM-1 in the adjuvant setting in HER-2 positive breast cancer patients with residual disease after neoadjuvant chemotherapy if neoadjuvant chemotherapy did not include anthracyclines?
The introduction of dual HER2 blockade has significantly increased the pathologic complete response rate of HER2+ disease to neoadjuvant therapy. The TRAIN-2 trial demonstrated that anthracycline based therapy did not increase the PCR rate over a taxane based regimen when dual blockade was used. APH...
How do you treat metastatic urothelial carcinoma after progression on immune checkpoint inhibitor?
Agree with @Dr. First Last. Enfortumab Vedotin is the current standard after checkpoint inhibitors and platinum-based chemotherapy, with no targetable mutation. The response rates for subsequent chemotherapy in the platinum-refractory setting are generally poor. I used Ramicurimab-Docetaxel (Petryla...
What are the preferred treatment options for platinum resistant clear cell ovarian carcinoma?
We often offer these patients a clinical trial, if one is available. Unfortunately, platinum resistant ovarian cancers have low response rates to chemotherapy, and clear cell cancers are particularly resistant. Doxil, weekly paclitaxel, gemcitabine, and bevacizumab are all reasonable options.
Would you add atezolizumab to carboplatin + etoposide for small cell/neuroendocrine prostate cancer?
This is an excellent question. While small cell lung cancer and small cell prostate cancer share common genomics (RB1, TP53 mutation or loss for example) and histology, they differ in many important ways including divergent evolution from AR positive disease in many patients with transformed disease...
How do you choose your next line of therapy for stage 4 GIST after progression on imatinib?
At Sylvester we have found that patients with GIST whose tumors progress in imatinib often harbor resistance mutations that may be detected by a blood test called “circulating tumor DNA”. There is growing evidence that patients with one type of mutation do much better with sunitinib while a differen...
How would you treat a patient who has progression of nodal metastases while receiving neoadjuvant gemcitabine/cisplatin?
This tumor biology appears resistant to cisplatin, therefore would consider alternative systemic therapy, e.g. clinical trial or immune checkpoint inhibitor or erdafitinib (if FGFR2 or FGFR3 activating mutation or fusion). The role of locoregional therapy depends mainly on the response on the system...
In patients who initially received chemo-hormonal first-line therapy for metastatic prostate cancer followed by abiraterone/enzalutamide for castration-resistant disease, would you re-challenge with docetaxel?
As we all know, very few things regarding therapeutic sequencing in prostate cancer are straightforward. Retreatment with docetaxel was used relatively commonly in the past in patients with mcrpc, especially in those with good initial responses primarily for want of other agents. In this setting, re...
When do you consider it too late after breast surgery to offer adjuvant chemotherapy to a patient with high risk non-metastatic breast cancer?
While we have evidence that it is beneficial to begin adjuvant chemotherapy soon after surgery, especially in younger patients with TNBC, we have no answers to the question of when it is 'too late' to start treatment. And while there are theoretical biologic advantages to starting treatment of possi...
How would you treat a patient with BRAF mutated Metastatic Melanoma who has progressed on targeted therapy (Encorafenib + Binimetinib) and Immuotherapy (Nivolumab/Ipilimumab), but yet maintain an excellent performance status?
Agree that clinical trial access would be ideal. If unable to access for any reason or to "bridge" if the patient is symptomatic, one might consider re-treatment with BRAF/MEK inhibitor based on phase II and retrospective data demonstrating response (Schreuer et al.: Combination of dabrafenib plus t...