Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Should additional molecular testing be performed on triple negative breast cancers up-front to identify potentially targetable mutations (e.g. activating HER2 mutations, homologous recombination repair deficiency assays, etc)?
My institution does not do this routinely. For metastatic triple negative breast cancer, I try to get them on a clinical trial first line and do any trial specific molecular testing that is required if any. But usually somewhere between 1st line and subsequent lines of standard therapy, I send the t...
How do you decide between initial radiotherapy vs systemic therapy in patients with metastatic melanoma and brain metastases?
An interesting question the answer to which is changing!For discussion we will assume that the patient is not previously treated. Presence or absence of CNS symptoms is likely the most important way to dichotomize these patients. Other issues include number and size of the brain metastases, whether ...
Would you consider pembrolizumab treatment in metastatic gastric cancer with absence expression of a single mismatch repair enzyme?
In the modern era, what volume of involvement is considered limited stage SCLC?
The TNM staging system (7th ed.) for lung cancer, which is the standard by which small cell lung cancer should be now staged, includes contralateral hilar and supraclavicular nodal involvement under the N3 rubric, resulting in a global stage IIIB designation. Most oncologists would thus consider the...
How would you treat stage 3 lymphocyte-predominant Hodgkin Lymphoma that is CD20 negative ?
First, I would verify the diagnosis with molecular testing of some sort. It is my opinion that nodular lymphocyte-predominant Hodgkin's lymphoma is universally CD20 positive. The disease is also rarely in stage III. Is it possible that the diagnosis is really another entity such as T-cell-rich B-cel...
Does anaphylactoid reaction to one immunotherapy agent exclude the possibility of using other immunotherapy agents?
Regarding PD1 inhbitors cross reactivity, I have never heard of patients having grade 3+ anaphylaxis with these agents. I have had several patients have infusion related reactions or delayed sensitivities from them. We, however, just re-challenge by slowing infusions rates, administering Benadryl (n...
Do you use off label olaparib in metastatic HER2 negative, BRCA2 positive breast cancer based on the OlympiAD data presented at ASCO?
Both olaparib and talazoparib have presented phase III trials in patients with advanced breast cancer and mutations in BRCA1 or 2 demonstrating more than doubling of response rates and significant improvement in progression free survival with an associated improvement in QOL compared to treatment of...
In which Her2+ breast cancer patients would you recommend extended adjuvant therapy with neratinib?
The benefit is largely in estrogen receptor positive patients and the gains are modest. Although with extensive and extended anti-diarrheal medications the almost intractable diarrhea seen with this agent can be made tolerable. On the other hand, it would take a VERY motivated patient, probably with...
Would you consider local therapy (e.g. XRT) in patients with mRCC with oligometastatic disease progression?
This is a good question. The role of local therapy in mRCC should (in my opinion) be limited to 2 settings. a) A patient with mRCC who is experiencing pain from a metastatic site. b) A patient with an indolent disease course and overall low volume of metastatic disease in whom local therapy such as...
How do you approach treatment for metastatic cutaneous squamous cell carcinoma after standard chemotherapy failure?
Immunotherapy seems to be active in cutaneous squamous cell carcinoma and I think checkpoint inhibitors are a good option for patients who have failed cytotoxic chemotherapy or cannot receive chemo. In an expansion cohort of a phase I study of REGN2810, a PD-1 inhibitor, the response rate in 26 pati...