Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with ILD and metastatic NSCLC with positive PD-L1, would you give chemo/pembrolizumab, chemotherapy alone, or pembrolizumab alone?
We always discuss the risks and benefits of treatment to every patient; however, patients still rely upon our best judgment to guide decisions. I would not recommend a PD-1 or PD-L1 inhibitor to a patient with known interstitial lung disease. These patients were excluded from the Keynote, Checkmate,...
What second line therapy do you use for metastatic gastroenterohepatic neuroendocrine carcinoma (G3 NEC) with progression after platinum based therapy?
In the absence of a clinical trial, I agree that FOLFIRI would be the best choice and is generally well tolerated as second line therapy. I would certainly offer tumor genotyping as NECs are generally high mutational burden malignancies which may identify drugable targets and eligibility for clinica...
How would you approach a metastatic ERBB2 amplified gallbladder carcinoma?
You have hit on a clinical scenario for which we have clues about helpful therapy, but no definitive data to guide us. For a HER-2 amplified gallbladder or biliary cancer, I do think the data support targeting this pathway at some point in the patient’s care. As you point out, the best data are from...
Do you recommend neoadjuvant radiation or chemoradiation for patients with T1-2 N0 adenocarcinoma of the anal canal prior to APR?
For the most part, anal adenocarcinoma is treated like rectal adenocarcinoma. Therefore, as the question is written, i.e. the patient will be getting an APR, I don't think there is enough data of a benefit for treating a T1-2 N0 adenocarcinoma with chemoradiation to justify the toxicity. However, i...
What chemotherapy regimen do you recommend with radiation therapy for cervical esophageal squamous cell carcinoma?
I would use weekly carboplatin/paclitaxel in this setting. Fluoropyrimidine + platinum is reasonable but will likely be more toxic, and I'm not aware of any data indicating that it's a more effective regimen.
Do you consider initiating systemic therapy for patients with NSCLC who develop oligometastatic disease and have all known sites of disease treated with SBRT?
This is a very intriguing and challenging question and addresses a not so uncommon clinical scenario when patients present with one or just a few sites of recurrent disease after delivery of what was considered to be definitive therapy. In such contexts many times it appears appealing and appropriat...
Do you offer neoadjuvant therapy to a postmenopausal cT1cN0 , HER2+, ER/PR+ breast IDC or recommend surgery first?
This is currently a very controversial topic, with likely no single straight answer - arguments can be made for both a neoadjuvant approach in light of the KATHERINE trial and for a surgery first approach with treatment de-escalation in light of the APT trial. As others have pointed out, the recentl...
How do you approach adjuvant chemotherapy for high grade large cell neuroendocrine lung cancers?
This is a challenging question given the absence of good data. We know from several studies using NCDB data that adjuvant chemotherapy in resected large cell neuroendocrine carcinoma of the lung is associated with better outcomes, at least for stage IB, possibly not stage I but keep in mind the NCDB...
Would you offer next-line systemic therapy to a patient with LGL leukemia with chronic severe neutropenia, who has had treatment failure with methotrexate, cyclophosphamide, cyclosporine, and danazol?
Response can be slow and delayed. Treatment failure is usually considered after 4 months of therapy. Steroids can be used with methotrexate in severe neutropenia with a slow taper over 4-6 weeks. This strategy seems to potentiate the effect of methotrexate. Evidence after these therapies is limited....
How much emphasis do you place on anti-AR therapy in a patient with metastatic castration resistant prostate adenocarcinoma with progressive neuroendocrine differentiation?
While most prostate cancers are adenocarcinomas, there is a histologic spectrum that includes neuroendocrine and small cell tumors -- with the later typically arising in response to chronic androgen deprivation therapy. Often times we are faced with mixed histologies, which can be challenging to man...