Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you re-challenge patients with an EGFR TKI beyond progression if repeated biopsies show redemostration of a sensitizing mutation (exon 19 deletion) and no other resistance mechanisms?
In a patient who has progressed after initial TKI based therapy and who lack a specific resistance mechanism (for example, a T790M in patients treated with first line TKI), my typical "next line" is chemotherapy (+/- immunotherapy - the IMPower 150 study showed the same hazard ratio for patients wit...
Do you offer adjuvant chemotherapy and/or radiotherapy for patients with resected atypical carcinoid of the lung with positive mediastinal lymph nodes (T3N2M0)?
I usually offer 4 cycles of adjuvant therapy with cisplatin plus etoposide for patients with surgically resected T3N2 atypical carcinoid tumor. Atypical carcinoid have intermediate chemosensitivity between typical carcinoid tumors and small cell carcinomas. I do not offer adjuvant therapy for typica...
Would you treat a patients with metastatic squamous cell lung cancer with >/= 50% PDL-1 expression with first line pembrolizumab/carboplatin/paclitaxel combination or with pembrolizumab alone?
With the recent FDA approvals of Venetoclax and Glasdegib in AML, is one generally preferred over the other for elderly and/or unfit patients in combination with a hypomethylating agent/low-dose cytarabine?
Overall the combination of venetoclax with HMA or LDAC for newly diagnosed older AML patients is generally preferred for treatment of this subset of AML patients due to reports of high overall response rates (60-70%) and prolonged overall survival (median 18 months). Prior studies have shown that gl...
Which regimen do you prefer for patients with newly diagnosed DLBCL that are not candidates for doxorubicin secondary to low ejection fraction?
I like to use R-CEOP per Vancouver experience. Had very good results with it and is very well tolerated. I sometimes use it also in frail older patients who have normal EF. Etoposide substitutes doxorubicin in regimen: 50 mg/m2 on D1 and 100 mg/m2 PO on days 2-3 and can also give peg filgrastim on D...
What is the optimal intrathecal chemotherapy regimen for leptomeningeal carcinomatosis from breast cancer?
For HER2- disease, we tend to do IT methotrexate or topotecan. For HER2+ disease, we routinely do IT Herceptin plus systemic treatments with a TKI like lapatinib with excellent long term control in some patients.
Do you use docetaxel interchangeably with paclitaxel in breast cancer?
The nuanced answer would be attuned to receptors, disease status (e.g. non-metastatic vs metastatic) and schedule.In the adjuvant setting, defining studies include E1199 (Sparano et al JCO 2015) and S0221(Budd et al JCO 2015). The ECOG trial examined weekly paclitaxel vs weekly docetaxel vs q3wk pac...
How do you decide between abiraterone or docetaxel for first line treatment of newly diagnosed metastatic prostate cancer?
Abiraterone (LATITUDE and STAMPEDE trials) and docetaxel (CHAARTED and STAMPEDE trials) both have level 1 evidence supporting their use in men with metastatic hormone-sensitive prostate cancer. However, a pre-planned subset analysis from the CHAARTED study demonstrated that docetaxel only appeared t...
How would you modify neoadjuvant chemotherapy for a stage 2-3 triple negative breast cancer who has baseline grade 2-3 neuropathy?
There are a few options I would consider. First, I would administer 4 cycles of dose-dense AC - assuming she has normal cardiac function at baseline - which typically has no significant neurotoxicity. If the patient has a very good response, I might stop there and send her to surgery. If she has had...
Would you recommend starting treatment for a renal cell carcinoma patient with new low-burden, asymptomatic sub-centimeter bilateral pulmonary nodules that arise after a short disease-free interval (<6 months) after nephrectomy for stage I disease?
This patient generally fits the phenotype of someone I would consider for initial observation. Usually if you look closely at prior scans, such nodules were present but unappreciated. There are prospective data supporting such an approach. Having said that, it also depends on the age and performance...