Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients who received neoadjuvant Imatinib for initially unresectable GIST tumours, do you routinely prescribe adjuvant therapy or rely on preoperative staging and preoperative mitotic index?
I agree with Dr Groisberg. Another way to look at it is that if the patient would have qualified by preoperative risk factors, I wouldn’t “downgrade” that by the improved risk tumor that comes out. Sometimes you can’t be sure ahead of time- for example I just saw a patient with a 3 cm duodenal tumor...
If you are treating a patient with palliative radiation for hemoptysis do you require chemotherapy to be held?
This is an interesting question. I would like to thank @Dr. First Last for his help with this. In recent years, I have rarely found myself asking colleagues from Medical Oncology to hold chemotherapy for patients who require palliative radiotherapy for hemoptysis. That being said, very few such pati...
When do you give exogenous albumin in an attempt to reduce risk of ifosfamide induced encephalopathy?
We don’t routinely give albumin as prophylaxis for ifosfamide induced encephalopathy (IIE). While there is an association between hypoalbuminemia and the risk of IIE, prophylactic replacement with albumin doesn’t appear to reduce the risk based on two retrospective studies at academic medical center...
How do you reconcile the difference with regard to adjuvant treatment recommendations when a breast biopsy reveals >10% ER+ but a subsequent lumpectomy of the same lesion is ER-negative?
Situations such as this typically involve review with pathology, including a second opinion review, to settle on one of two basic camps of possible explanations: 1. Heterogenous cancer or even possibly multiple primaries with differing receptors. Although not common, some cancers are heterogeneous w...
How would you treat a metastatic lung adenocarcinoma with MET exon 14 skip mutation on ctDNA, negative tissue NGS and PD-L1 of >50%?
I would treat this patient with single-agent pembrolizumab. If they had rapidly progressing disease with worsening symptoms or if they were a never smoker, I would favor carboplatin/pemetrexed/pembrolizumab in order to optimize rapidity of response. These recommendations are based on the results of ...
Can invasive lobular cancer be triple negative?
The short answer is yes. The longer answer is that it is very unusual and should trigger a re-review to make sure that the findings are correct. In a SEER database analysis of ILC vs. IDC that included 85,048 ILC cases and 711, 287 IDC cases, only 4.1% of the ILC cases were both ER- and PR-negative....
How would you treat a young female with a recurrent triple negative breast cancer to the contralateral breast?
I would imagine 3 years later in the contralateral breast that this would be a new primary. We would want to treat this as its own separate cancer. I would avoid anthracycline as she has already received this but what specific chemotherapy I would pick depends on the tumor size and lymph node sta...
Would you recommend adjuvant chemoradiation for a resected ampullary adenocarcinoma?
There is no clear cut answer to this question. There is suggestive evidence from retrospective studies that adding radiation therapy to a chemotherapy regimen improves outcomes, but those are retrospective and non-randomized, with all the inherent difficulties in those analyses. The limited randomiz...
Has the recently published SELECT trial of adjuvant erlotinib in early stage EGFR-mutant NSCLC impacted your management of these patients?
The SELECT trial was a well conducted single arm trial of post-operative adjuvant erlotinib in early stage patients with NSCLC bearing an activating EGFR mutation. Compared with historical controls with and without EGFR mutations, the disease free and overall survival were superior. The study establ...
How do you choose between atezolizumab, bevacizumab, carboplatin, paclitaxel (IMpower 150) vs. pembrolizumab plus chemotherapy (KEYNOTE 189) in patients with metastatic NSCLC?
This is a great question. As we are all well aware, the combination of chemotherapy and immunotherapy has become a standard of care for some patients with advanced non-squamous NSCLC. Both the IMPOWER trial published by Socinski et al. in NEJM and the KEYNOTE 189 trial published by Gandhi et al. in ...