Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Will you offer Ibrutinib and Rituximab for untreated patients with CLL without a 17p deletion?
The ECOG 1912 study presented at ASH this week showed better OS and PFS in younger patients with ibrutinib, which was great news. I used to use FCR in these patients as it was said to have a higher rate of MRD but potentially dangerous myelo- and immunotoxicity and of course there's concerning issue...
What is your preferred first-line therapy for a patient with standard risk multiple myeloma?
Tough question. Let's do the easy ones first. The low risk (R-ISS 1) fit patient could be treated any number of ways with Bortezomib+Lenalidomide+Dexamethasone (RVd), Carfilzomib+Lenalidomide+Dexamethasone (KRd), or Daratumumab+Lenalidomide+Dexamethasone (Dara-Rd). Bortezomib can lead to neuropathy...
Do you consider additional chemotherapy or durvalumab after definitive concurrent chemo/RT for Stage II NSCLC for patients who are not surgical candidates?
Staging is man-made and somewhat capricious and as stands now essentially completely unmoored from biology in NSCLC. Durvalumab is obviously very moored to biology in NSCLC. There are times we "extrapolate" in oncology; it's tough not to do this in settings where no *specific* data exists but "adjac...
How would you treat a patient with an inflammatory triple negative breast cancer with contraindications to an anthracycline?
No easy answer. We all can agree that we need to achieve the pCR to have the long-term best outcome. The standard regimen for triple negative primary IBC is AC x 4 cycles followed or preceded by paclitaxel weekly x 12 cycles. I am not quite sure why you can not administer anthracycline, but I am goi...
Do you offer durvalumab to patients with stage IIIB NSCLC after chemoradiation if they are also on long term dialysis for ESRD?
Antibodies are generally not dialyzable with conventional methods. Given the cancer diagnosis, these patients are not candidates for transplant in the short term. With a prognosis of advanced stage NSCLC worse than the prognosis arising from ESRD already on long-term dialysis, I will offer the optio...
Would you extrapolate data from PACIFIC trial for unresectable disease to consider consolidation therapy with durvalumab for Stage III NSCLC with single-station N2 disease amenable to lobectomy?
I agree with both answers above. The question about adding durvalumab after chemo-RT and lobectomy continues to come up. I would not extrapolate the data from PACIFIC to this situation. First, its important to point out that its not indicated in this situation - the approval for durvalumab in the US...
What is your approach to asymptomatic patients with progressing lung metastatic adenoid cystic carcinoma originally arising from the trachea?
In my practice, it depends on the disease burden and the rate of progression. If it's very slow, and the disease burden is modest, which is not uncommon, then often the risk of potential side effects can outweigh the potential benefit, given the lack of good data on systemic treatment, especially on...
How would you manage adjuvant therapy in a BRCA1-mutated woman with ER+, Her2 negative breast cancer with residual disease at surgery after neoadjuvant therapy with a taxane-based regimen?
There are several factors to consider in this case. One is whether the patient has received optimum chemotherapy. If there is only minimum residual disease at surgery, I would not recommend additional chemotherapy in the adjuvant setting. On the other hand, if there was significant residual disease ...
What would you use as next line of treatment for a patient with ROS1+ metastatic NSCLC progressing on first line TKI?
The finding that crizotinib was quite active in ROS1 altered cancers (Shaw et al., PMID 25264305 - confirmed in East Asian patients - Wu et al., PMID 29596029) obviously altered the practice of thoracic oncology, and led to the approval of crizotinib in patients with ROS1 translocations. Moreover, t...
What is your preferred third line approach for a patient with refractory small cell lung cancer who has failed second line therapy with nivolumab after recieving first line platinum based therapy ?
I would prefer a clinical trial or perhaps a taxane, but I have added ipilimumab to nivolumab in this situation, despite the lack of data. The results remain to be seen!