Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with head and neck squamous cell carcinoma and adverse features with borderline renal function in the adjuvant setting?
In the postoperative setting, bolus-dose cisplatin (80-100 mg/m2) every 21 days with radiation is the preferred treatment for patients with positive margins or extranodal extension. If patients cannot tolerate high-dose cisplatin, weekly cisplatin can be considered. In one randomized study of SCCHN ...
Do you offer pembrolizumab monotherapy or carbo-pemetrexed-pembrolizumab to a patient with Stage IV large cell NSCLC with PD-L1 of 80% and KRAS+STK11 mutation?
This is a good question. My opinion is first that the KRAS is irrelevant and only studied because of the mouse model. The entire effect is from LKB1, independent of KRAS. Second, that this has not been tested in any of the randomized trials looking at IO vs. IO/chemo vs. chemo, so its predictive abi...
Is there any evidence to treat the primary breast tumor with local therapy after a radiographic CR with systemic therapy for stage IV disease?
Resection of the primary breast cancer in setting of stage IV is the question in a number of prospective randomized trials and the answer we have to date there is no overall survival advantage, except in the very small number of patients with a solitary bone mets. However, we know HER2 positive wome...
Is there any reason to switch endocrine therapy after a patient undergoes bilateral oophorectomy?
In my opinion, in the absence of progressive disease, I would maintain this young woman on tamoxifen as long as there were not progressive disease and the tamoxifen was well tolerated. Now that she has had an oophorectomy, and has been rendered menopausal, there will be many options when progressive...
How do you approach an ER negative, PR positive, Her2 negative breast cancer in terms of hormone manipulation based on PR status alone?
This is a very interesting question. My practice is not to utilize anti-estrogen in true ER Negative /PR positive cases ( after repeating the assay on another tissue sample to rule out a false negative ER assay). EBCTCG meta analysis of randomized trials published in Lancet in 2011 showed only sligh...
Would you consider using a PD-L1 inhibitor after progression on a PD-1 inhibitor for metastatic NSCLC?
We do not have direct evidence to assess this question, but in the absence of data, I have been quite skeptical that switching from a PD-1 to a PD-L1 inhibitor would be an effective strategy. I think that the most direct data that I can offer from studies in which I have been involved is a study of ...
Is it routine to check imaging during or after neoadjuvant chemotherapy for breast cancer to assess for a radiographic response?
I think the issue of checking imaging studies during or after neoadjuvant is only it if will change your management. For example, if you cannot assess clinical response in the breast and axillary during neoadjuvant therapy then imaging might reveal progression, in which you case the patient is heade...
What is the standard of care (if any) for pediatric desmoplastic round cell tumor?
I am an adult oncologist and will defer to a pediatric oncologist if one is available to specifically address the question asked. Multidisciplinary evaluation in a sarcoma center is essential. For adults with this diagnosis, we manage desmoplastic small round cell tumors along the lines of Ewing sar...
How do you approach adjuvant therapy for a resected gastric GIST when the risk for recurrence is discordant between various prediction tools?
For intermediate risk patients, I generally have a discussion with the patient surrounding the risk of recurrence vs the potential toxicity of adjuvant therapy. Some patients will opt for surveillance and others will be more comfortable starting adjuvant imatinib. A nomogram that I find especially h...
How do you monitor patients with metastatic breast cancer?
NCCN Guidelines recommend regular office visits, lab testing, and imaging studies, but there is a wide range of recommendations for the frequency, i.e. 6 weeks to 6 months and these are not based on prospective data. NCCN and ASCO guidelines recommend that metastatic disease be monitored in selected...