Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to initial management of patient with clinically palpable axillary disease, histologically proven breast cancer, with no imaging evidence of an occult primary or metastatic disease?
The frequency of TXN+M0 cases has declined with the availability of breast MRI, as many cancers occult on mammography and ultrasound are detected by MRI, but they still occur, and are usually high grade, triple-negative or HER2+. I treat these as I would any patient with node-positive disease, with ...
What would you recommend as a first line systemic therapy for metastatic sarcomatoid carcinoma of the lung without driver mutations?
There is no right answer for this question. The only trials that I am aware of for sarcomatoid carcinoma/carcinosarcoma are in uterine primaries and we don't know if those findings are transferable to other sites. I tend to use carboplatin/paclitaxel/bevacizumab for pulmonary sarcomatoid carcinoma. ...
How do you approach ER, PR weakly positive, HER2 negative breast cancer in the metastatic setting?
Adjuvant studies have suggested benefit to hormone therapy in low ER positive patients, although the absolute benefit may be less. In the metastatic setting, the decision to approach low ER positive, HER2 negative patients with endocrine therapy versus chemotherapy depends on the individual patient ...
How do you approach a patient with DPD deficiency that experiences severe toxicity on 5-FU despite dose reduction in the setting of metastatic colorectal cancer?
This depends on the mutation. Most patients heterozygous for DPYD mutations can be treated with dose-reduced 5-FU or capecitabine. Guidelines from CPIC (Clinical Pharmacogenomics Implementation Consortium) give recommended dose reductions for specific genotypes - a 50% dose reduction is appropriate ...
Is Ki-67 expression routinely performed on ER+ breast cancer patients and do you find that information useful for making treatment decisions?
Our institution's pathologists do not routinely test for or report Ki-67 expression in any subtype of breast cancer; while I sometimes see this value on path reports from outside institutions in patients referred for consultation or second opinion, I am hesitant to use it to determine treatment reco...
What would be your choice of endocrine therapy for a patient with HR+ early stage second breast primary after completing 5 years of adjuvant AI?
There are no studies to provide guidance in this situation as far as I am aware as most adjuvant studies excluded patients with prior history of breast cancer. Given that the second primary breast cancer was discovered 2 years after completion of adjuvant aromatase inhibitor, it probably developed a...
How do you approach your choice of systemic therapy for relapsed/metastatic H&N cancer (failed definitive concurrent chemoRT) not amenable to further locoregional therapies?
If patients fail CRT with a platinum-based regimen within 6 month of the completion of treatment, I generally give them I/O therapy. If > 6 months, the SOC right now is to treat with a platinum based regimen, i.e. EXTREME regimen or a platinum doublet. I will often give a modified version of EXTREME...
Do you use cabozantinib preferentially over other TKIs in mRCC patients who have progressed on immunotherapy with primary metastatic burden being bony disease?
Cabozantinib sounds a very good option in that scenario extrapolated from data from the METEOR (but differences in prior therapy) & CABOSUN trials (in different line of therapy). If a patient can tolerate it, it is a very reasonable option.Other VEGF TKIs (e.g. axitinib, sunitinib, pazopanib), lenva...
In which clinical situations, if any, would you use imiquimod for treatment of breast cancer skin metastases?
Imiquimod is synthetic toll-like receptor (TLR)7 agonist that has immunostimulatory effects when applied topically. Topical application can enhance clearance of human papillomavirus (HPV)-​related genital warts, and might lower cancers associated with HPV, and is approved for that purpose. It has ...
How would you treat frontline metastatic ER+HER2- breast cancer with activating PI3K mutations?
Outside of a clinical trial, I would still treat patients with HR+/HER2-, PIK3CA mutant, metastatic breast cancer with hormone therapy + CDK 4/6 inhibitor. At this moment, we are still awaiting approval of alpelisib. In the phase 3 SOLAR-1 trial, 341 patients with PIK3CA mutant tumors were randomize...