Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you consider multifocal disease an indication for chemotherapy with trastuzumab in patients with microinvasive Her2+/HR- breast cancer?
Not necessarily those with just 2 or 3 foci of microinvasive disease, but I am concerned when a patient has multiple (though I'm not sure if the number is 4 or 7 or 10) foci of microinvasion within a sizable area of high-grade, ER- DCIS, especially when the pathologist says that there are too many f...
What first line treatment would you choose for stage IV adenocarcinoma of lung with ALK gene rearrangement and PD-L1 TPS 95%?
If you follow FDA labels, you cannot use first line pembrolizumab on a patient with EGFR or ALK aberration unless they have failed targeted therapy first. So that is problem # 1, insurance may deny use of first line immunotherapy in a patient with ALK (+) NSCLC. I am not aware of a head to head comp...
How do you manage a patient with newly diagnosed stage IIA triple negative breast cancer with a history of renal transplantation on immunosuppressive therapy?
A thorough understanding of their immunosuppressive medication regimen, concomitant medications, comorbidities, and baseline graft status from their transplant doctors is important prior to treating the patient so risk/benefit can be assessed. Running their medications up against Micromedex or in co...
Would you offer chemotherapy to a patient with an in-breast recurrence less than 2 years after a history of lymph node positive ER+PR+HER2- breast cancer treated with mastectomy and adjuvant hormonal blockade?
To clarify things, do you mean chest wall recurrence post-mastectomy, a in-breast recurrence in a nipple sparing mastectomy, or a new primary in the contralateral breast? First, with each of above scenarios it is a good idea to re-stage the patient. Secondly, given the two-year disease-free interval...
How would you treat patients with muscle-invasive urothelial carcinoma of the bladder with small cell and sarcomatoid differentiation?
Muscle-invasive urothelial carcinoma "with small cell and sarcomatoid differentiation" could represent an inexperienced pathologist failing to recognize a variant of pure urothelial cancer or it might be a stem-cell tumor with variable differentiation. I would start by having the pathology reviewed ...
Do you still consider surgery for N2 NSCLC in the era of consolidative immunotherapy?
Yes. We still consider surgery for selected patients after chemoradiation for stage IIIA NSCLC. However this decision is made prior to starting induction therapy.
What dosing regimen of carfilzomib do you use in the front line setting for high risk transplant-eligible multiple myeloma?
I almost never use carfilzomib in the front line setting, as there is almost no evidence to support its use over bortezomib in this setting. When I do give carfilzomib in combination with lenalidomide, I generally extrapolate from the twice weekly 36 mg/m2 dosing and combine those into a single week...
Would you use standard neoadjuvant chemoradiation for a patient with advanced rectal cancer and a history of previous pelvic RT for another cancer?
No. We have to remember that the benefit of radiation in locally advanced rectal cancer is limited to a local control benefit; and must balance the risks/benefits as such. Moreover, there are T3 tumors with an uninvolved mesorectal fascia(1) where the role of radiation may be more limited; since a T...
What is your preferred second-line of treatment for metastatic gallbladder carcinoma after progression on gemcitabine/cisplatin in a young, fit patient?
There is currently no standard of care for second-line therapy in biliary tract cancers after front-line cisplatin/gemcitabine. During front-line therapy, I routinely send these tumors for molecular profiling, as targetable mutations are relatively common in biliary tract cancers and differ based on...
Do you give Her2 targeted therapy in patients with breast cancer with Her2 testing showing FISH ratio equal or more than 2.0 but Her2 copy number less than 4.0, with further testing showing IHC 1+?
According to the latest ASCO/CAP clinical practice guidelines updated focus: HER2 testing in breast cancer published in JCO 2018, if a case has a HER2/CEP17 ratio of ≥2.0 but the average HER2 signals/cell is <4.0, IHC testing for HER2 should be performed using sections from the same tissue sample ...