Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adding atezolizumab to a different chemotherapy/platinum-doublet backbone from the IMpower 133 trial for a new ES-SCLC patient?
No I would not, primarily for these reasons: 1) There are no clinical data of which I am aware regarding the addition of atezolizumab to irinotecan and cisplatin for any tumor type. 2) Irinotecan/cisplatin is more toxic than etoposide/platinum regimens, with no improvement in efficacy in 1L extensiv...
What recommendations do you make regarding the use of biologics for uncontrolled Crohn's disease in patient's who have a history of DLBCL that developed while on infliximab and azathioprine and whose lymphoma is essentially cured?
This is a frequent question without a clear answer. There has not been a randomized study of anti-auto-immune therapy strategies to define the risk of a relapse or secondary lymphoma in patients with a clear need for treatment. I recommend the patient work with their rheumatologist to start a low i...
When do you recommend broader molecular testing for clinical trials in stage IV NSCLC patients who have negative initial molecular testing for FDA-approved targetable mutations?
How do you choose between regorafenib or TAS-102 in patients with metastatic colorectal carcinoma that has progressed on all prior 5-FU based regimens and anti-EGFR therapy?
Despite their FDA approval, both TAS-102 and regorafenib are equally marginal drugs in terms of their efficacy. In the world of GI Oncology, there are those of us who do and do not treat HCC; those who do have experience with sorafenib and regorafenib and find both drugs to be "tolerable". On the ot...
How do you decide on the type of ovarian suppression (GnRH agonist vs. GnRH antagonist) in premenopausal patients treated with an AI?
Based on current available literature in Breast Cancer it is premature to change to GnRH antagonist such as Degarelix. While action of onset is more rapid with Degarelix (3 days) versus triptorelin (14days) (GnRH agonist) side effects are more pronounced and efficacy data is still lacking. In the re...
In patients with stage II-III HER2+ breast cancer who were not treated with neoadjuvant therapy, without having knowledge of response to neoadjuvant therapy (i.e. pCR or not) after chemotherapy, what is your preferred adjuvant HER2 directed therapy?
I largely agree with @Dr. First Last. I am also underwhelmed by the APHINITY data and limit TDM-1 to patients with residual disease after neoadjuvant therapy that includes trastuzumab +/- pertuzumab. And, while I am sure that they exist, I have yet to see the patient to whom I would recommend nerati...
How would you manage CML first-line second generation TKI with a best response of MMR 4, but now with a loss of MMR with more than one log response loss but still in complete cytogenetic remission and mutation panel negative?
The easiest would be to repeat the test in 1 month or so. If the results show persistently increased levels, then I would monitor the patient closely. I would also review any new medications for possible drug to drug interactions. I would also review the patient's adherence, does the patient still h...
Can you use Mammaprint to decide on chemotherapy in a young patient with positive sentinel nodes if no further axillary dissection is planned to see if there is more nodal involvement?
Mammoprint is the only genomic assay with level one evidence in node positive patients. Assuming that no axillary dissection to be done suggests ACOSOG Z-11 in a lumpectomy patient. Most would agree that taking more than one sentinel node decreases the risk of false negative assays so, in a patient ...
What factors affect your decisions in in the initial management of a stage IIIB bladder cancer?
For cN+ bladder Ca, I start with induction chemotherapy aiming for 4-6 cycles (restaging initially after 3 cycles and continue to 1-3 more cycles depending on response & tolerance) since the risk of micro-Mets is exceedingly high. If a patient has a great response to induction chemo, options may be ...
How do you treat patients with sensitizing EGFR mutations who progress on osimertinib with small cell transformation, but with persistent EGFR mutation detected in the peripheral blood or tumor?
There are no studies to directly address this issue. For sure the patient needs chemotherapy with etoposide/platinum. Whether osimertinib should be continued during the chemotherapy or re-instituted after 4 cycles of EP has not been studied. I would give both.