Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is it safe and/or necessary to combine osimertinib and carboplatin/paclixel for a patient with stage IV EGFR mutated NSCLC and advanced ovarian carcinoma?
This is a tough situation and a lot depends on the status and urgency of the ovarian cancer and whether surgery is planned for it. I would not combine the chemotherapy and osimertinib simultaneously for sure. There are several studies that show the combination of chemo and TKI is not as good as TKI ...
Do you recommend sending Oncotype for bilateral synchronous primary ER+ breast cancers?
Yes I would recommend OncoType Dx for bilateral synchronous primary ER+ breast cancers. A couple of studies, although with a small sample size, have looked at this. The first one by Karsten et al (Ann Surg Oncol. 2016) showed only a 67% concordance rate for recurrence score by Oncotype Dx for synchr...
How would you approach a young patient with a prior ER+ HER2- breast CA now local recurrence that now has Her2 positive disease?
For Her-2 positive disease, I would definitely choose chemotherapy with anti Her-2 agent(s). With Her-2 positivity and a young age, the patient is at high risk for recurrence which can be significantly reduced by the addition of anti Her-2 agents to chemotherapy. Although this is a local recurrence,...
For patients with stage I NSCLC initially treated with SBRT, how do you best manage isolated regional nodal failure?
The 5-year loco-regional failure rate in RTOG 0236 was 38%, underscoring that there is considerable need for identifying a post-SBRT salvage strategy for these patients; there are only anecdotal reports in the literature as to how to best manage these patients. Our historic approach when the failure...
How would you approach oligometastatic (solitary) recurrence with previously resected pancreatic adenocarcinoma and adjuvant chemotherapy with a prolonged disease-free interval?
This is very different from colon cancer with a solitary recurrence after a long disease-free interval. In this case, before considering any local therapy, I would treat with a course of systemic therapy to establish favorable disease biology. The vast majority of patients with recurrent, oligometas...
Do you routinely add eight extra rituximab doses to six cycles of R-CHOP in elderly patients with DLBCL treated with miniR-CHOP as done in SMARTE-R-CHOP-14 trial ?
I rarely give R-mini-CHOP and even when starting with that regimen I will attempt to escalate as tolerated to standard dosing in elderly patients and as such don’t see much benefit in extra rituximab.
How would you treat a patient with a history of ER+ breast cancer over 10 years ago, now presenting with an ER+ loco-regional recurrence while still on Tamoxifen?
Management of loco-regional recurrence is primarily local therapy. In this patient with ER positive LRR (HER2 negative), the first decision is to decide if this is operable. If operable, the first step would be surgical resection and consideration of local radiation. As far as systemic therapy, I wo...
What is your strategy for image surveillance for occult breast cancer after treatment?
As the are occult with all imaging including MRI there is no good strategy for imaging . Also risk of IBTR in modern era after RT in these patients is low and would just do routine annual mammogram for screening
When do you add an adjuvant bone-modifying agent in patients with history of localized breast cancer?
In my opinion this is controversial question. The meta-analysis performed by EBCTG 2016 of over 11,000 post-menopausal women, and over 6000 premenopausal women, clearly shows a benefit for the postmenopausal subset. The absolute overall survival improvement was 3.3% (p=0.002) for postmenopausal wome...
How do you interpret and manage discordant HER2 in IDC breast cancer between primary tumor and lymph nodes?
Trastuzumab and Pertuzumab have made such significant contributions to decreasing breast cancer mortality that I would give irrespective of which site (breast or axillary) is positive. Speculate as why the breast primary is HER2 overexpressing and the nodes are not are 1) falsely negative assay for ...