Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are non-clinical trial options to treat high-risk MDS in a transplant ineligible patient, after progression on hypomethylating agents?
This is often a difficult discussion to have with patients as there are currently no FDA approved second line treatment approaches for such patients, but this remains an active area for clinical investigation. Some approaches are nicely reviewed in Dr. Santini's 2019 How I Treat article in Blood.In ...
How would you approach adjuvant therapy for a post-menopausal women with cT2 cN0 TNBC on biopsy s/p neoadjuvant chemotherapy and mastectomy who is later found to have RCB2 HR+ breast cancer on surgical pathology?
First, is she BRCA positive? If so, there is a role for olaparib in adjuvant setting (OlympiA trial). I would treat with capecitabine as per the CREATE X trial (Masuda et al., PMID 28564564). Although the subset of triple negative cancers benefited most, and the point estimate for the ER or PR posit...
Would you use encorafenib with cetuximab vs encorafenib alone as second line therapy in a patient with metastatic colon cancer with concomitant KRAS G12V and BRAF V600E mutations identified on liquid biopsy?
I would rather state this question as, "Would you use encorafenib with cetuximab or cetuximab with encorafenib plus binimetinib (triplet regimen), or cetuximab in combination with irinotecan based chemotherapy?"Based on the available data, it seems like KRAS mutation was not relevant. BEACON trial (...
What tumor-related factors help in deciding between BRAF/MEKi vs ICI in stage IV BRAF mutant melanoma patients?
Any patient who has a contraindication to ICI (autoimmune disease, transplant, etc...), I start with BRAF inhibitors, unless the patient is eligible for a clinical trial. Otherwise, I start with ICI, given the latest results of ECOG EA6134. Whether I choose combo with ipi and single agent PD1 inhibi...
What is your preferred first line treatment approach for a patient with PDL-1 high (>50%) NSCLC presenting with CNS mets?
The treatment decision and sequencing in patients with brain metastasis from non-oligometastatic NSCLC with high PD-L1 expression and no traditional actionable genomic alterations depend on size and location of brain mets as well as associated symptoms.Based on data from several prospective and retr...
Would OncotypeDx impact your decision to provide adjuvant chemotherapy for node-negative HR+ breast cancer with dermis or chest wall involvement?
While I'm tempted to use Oncotype or other genomic assays to omit chemotherapy as much as possible (and TBH, Oncotype may be more of a prognostic than predictive assay except at the very upper range - see Mitch Dowsett's examination of these assays, Buus et al., PMID 33108242), the prospective trial...
Would you hold osimertinib in a patient with a STEMI, and for how long?
Compared with other EGFR TKIs, osimertinib seems to have a higher risk for cardiac events including decreased LVEF and prolongation of QTc. In an interesting analysis utilizing the FDA Adverse Events Reporting System (FAERS), investigators found that, when compared with all drugs reported in this da...
Do you send OncotypeDx testing in breast cancers with mucinous histology?
I don't send Oncotype in pure mucinous tumors routinely. NCCN doesn't recommend adjuvant chemotherapy for node negative favorable histology tumors due to their good prognosis. Retrospective studies (Turashvilli et al., PMID 28702894, Wang et al., PMID 30619463) show the majority score low to interme...
Would you offer adjuvant chemotherapy, osimertinib, or both to a patient with Stage IB EGFR mutated lung adenocarcinoma found in the lung explant pathology after bilateral lung transplant?
This is such a rare and individualized case that there will likely be no correct answer. My understanding of the facts is that stage IB lung adenocarcinoma was found on the removed explanted lung after a lung transplant. The question posed is what is the role of adjuvant systemic therapy? Ignoring t...
How do you differentiate between JAK2 positive ET and PV when peripheral blood shows erythrocytosis and thrombocytosis?
The answer to this question is very simple. Before the discovery of erythropoietin and accurate assays for it, and before the discovery of JAK2 driver mutations, the diagnosis of polycythemia vera was clinically-based. The Polycythemia Vera Study Group (PVSG) did an extensive epidemiologic study and...