Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
With the approval of frontline pembrolizumab monotherapy for advanced NSCLC with PD-L1 of 1% or above, how do you select who gets Chemo-IO versus pembro monotherapy if PD-L1 between 1-49%?
Most patients with PDL1 1-49% should continue to be offered chemotherapy + IO and not pembrolizumab alone.
Do you implement an age cut-off for determining use of adjuvant chemotherapy for Stage III ER+ PR+ breast CA?
No. But, I carefully assess functional age based on patient's daily activity level. If the patient has poor functional status, and has a high risk of cancer recurrence, I use clinical judgement to determine the value of adjuvant chemotherapy and discuss the pros/cons with the patient.
Do the results of S0226 change your endocrine therapy of choice in denovo metastatic hormone positive breast cancer?
S0226 compared anastrozole to anastrozole plus fulvestrant loading dose in first-line treatment of metastatic ER-Positive Breast Cancer. The combination arm was more effective than anastrozole alone, with a significant improvement in PFS and OS. This concept of complete ER blockade has been an attra...
What would be your approach in a patient with MET amplification and PDL-1 80% expression?
Need to clarify whether it is very high amplification ( need to verify with NGS provider). If high, can consider off-label Crizotinib ( these tend to metastasize to brain more frequently. Else, can start chemoimmunotherapy and switch to Crizo on progression , or one of the newer agents if approved b...
Would you offer adjuvant chemoRT to a patient with pancreatic adenocarcinoma who underwent neoadjuvant therapy with FOLFIRINOX and SBRT but had a positive (neck) margin on resection and is now s/p adjuvant chemotherapy?
This is why low dose, small volume SBRT is a flawed neoadjuvant treatment. This is possibly a marginal miss. It rarely happened in the past with conventional pre-op treatment but now it is happening commonly. Many patients are suffering because of it. It is important to assess the margin was in the ...
What systemic therapy would you offer a postmenopausal women with oligometastatic sternal disease which developed while on tamoxifen?
For an isolated sternal metastasis, I would normally refer to radiation oncology for focused radiation, and I would change her hormonal therapy to an aromatase inhibitor, as these patients can have very long survival times. Some patients survive longer than a decade. (Milano MT et al). Having a sing...
If a patient achieves excellent clinical/radiographic response to neoadjuvant THP, would you omit AC and proceed with surgery?
If a patient has had only 4 cycles of THP (similar to the NeoSphere Trial preoperative component), then the standard of care is still to proceed with anthracycline-based therapy as we do not yet know if the favorable outcome associated with pCR applies to abbreviated therapy. However, for a patient ...
What is the role for "liquid biopsy" for patients with newly diagnosed metastatic NSCLC?
I send ctDNA on essentially every new diagnosis of metastatic lung cancer in my clinic. This is for a few reasons. The major reason is that I find these tests come back in about 7-10d on average, and while we have relatively rapid tissue-based NGS-based testing for actionable biomarkers with our pat...
How do you mitigate the risk of hearing loss for patients requiring cisplatin?
I have seen some centers do baseline audiometry testing for all patients to at least give a baseline if the patient then complains of tinnitus or other hearing changes during treatment. I'm not sure how much this helps without also doing surveillance during treatment and it hasn't become my standard...
Would you offer adjuvant chemotherapy in a patient with extensive LCIS/DCIS s/p mastectomy and multiple positive lymph nodes due to surgical seeding?
I don't believe that multiple positive lymph nodes should be attributed to 'surgical seeding' alone, as opposed to invasive disease not visualized in the breast specimen (or apparent on preop imaging that included the axilla). Would ask my pathologist to perform receptors on the disease in the nodes...