Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to systemic treatment of a rapidly progressing, symptomatic, unresectable MPNST arising from a plexiform neurofibroma in a patient with NF1?
The activity of the MEK inhibitor is selective for the benign NF/PN. For the malignant transformation, with aggressive behavior, the SOC chemotherapy regimens are preferred. The SARC trial tested Dox/Ifex and Ifex/VP-16, and these remain the preferred front-line regimens.
Would you offer adjuvant chemotherapy for a large, high-grade radiation-induced malignant peripheral nerve sheath tumor following R1 resection?
I assume a post op scan shows no gross disease. Technically this is not "adjuvant" since there is known microscopic residual disease. In a young patient with good PS and organ function, it's reasonable to discuss risks and benefits of systemic chemotherapy (Doxorubicin + Ifosfamide) now vs. close f/...
How would you approach therapy for an elderly patient with NF1-associated metastatic MPNST who remains asymptomatic?
The decision should be based on the extent/bulk of disease, rapidity with which it may be growing (or not), PS/organ function/co-morbidities and of course, in this incurable situation, the COVID-19 crisis. Since patient is asymptomatic and assuming you are not worried about impending symptoms, short...
Can a breast cancer patient who received chemotherapy with AC during her 3rd trimester breastfeed before resuming chemotherapy postpartum?
Yes, completing the course of chemotherapy after 6 months of breastfeeding is likely better than not completing it. This is mostly based on the assumption that the chemotherapy sensitivity of micrometastasis is unlikely to change too much over 6 months. If it was potentially curable 6 months ago, it...
After an optimal tertiary cytoreduction for recurrent granulosa cell tumor previously treated with BEP and hormonal therapy, would you recommend systemic chemotherapy?
Yes, I would give adjuvant therapy. I would go with carbo taxol. The MD Anderson people have been using this regimen for some time. It is less toxic and appears to be as active as BEP. I think Jubilee Brown published a paper on this subject recently. This exact meeting was not specifically addressed...
How would you treat a patient with end-stage renal disease, a germline BRCA1 mutation, and pT1c pN0 TNBC s/p mastectomy?
To better address this question, I have consulted our phenomenal specialty pharmacist at our breast cancer program, Dr. Michael Berger. Based on the information he provided, doxorubicin and paclitaxel can be given at full doses in patients with end-stage renal disease (ESRD) as these agents are meta...
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
What is your preferred first line therapy for ROS1 rearranged metastatic NSCLC without CNS mets?
I think this is a particularly difficult question, but in the end, I generally would lean towards crizotinib. The TRK inhibitor toxicities including lightheadedness/dizziness can be difficult, and overall there does not seem to be a clear benefit of entrectinib over crizotinib (outside of entrectini...
When would you opt for a chemotherapy free approach in the first line treatment for hairy cell leukemia?
This is an outstanding question and there are a few reasons to consider treatments other than cladribine or a chemotherapy-free approach. I have considered and used alternatives in special situations, mostly those with infections. I will limit this to the treatment of classic hairy cell leukemia as ...
When would you opt for a chemotherapy free approach in the first line treatment for hairy cell leukemia?
This is an outstanding question and there are a few reasons to consider treatments other than cladribine or a chemotherapy-free approach. I have considered and used alternatives in special situations, mostly those with infections. I will limit this to the treatment of classic hairy cell leukemia as ...