Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would be your approach to a patient with a PIK3CA mutation after progressing on multiple lines of chemotherapy, immunotherapy and PARPi for gBRCA mutated metastatic TNBC?
Would recommend the patient go on a clinical trial of inhibitors against PI3K or AR. Mutations in PIK3CA occurs in approximately 7-9% in TNBC. AR pos TNBC has a higher likelihood of PIK3CA mutation. In the LOTUS trial, the addition of ipatasertib (AKT inhibitor) to paclitaxel improved PFS in patient...
What is your preferred first line therapy for ROS-1 rearranged metastatic NSCLC for patients presenting with CNS metastases?
The recognition of ROS1 as a distinct actionable translocation in NSCLC, and approval of crizotinib in 2016 based upon an expansion cohort of the original phase I study of crizotinib (N Engl J Med. 2014 Nov 20;371(21):1963-71) was an important step. Unfortunately, the limitations of crizotinib in AL...
For elderly women with good PS, when would you omit adjuvant anthracycline for early stage HR+,HER2- breast cancer with a high Oncotype Dx score?
I seldom recommend the use of an anthracycline in older patients with early stage HR+/HER- breast cancer, even when a high Oncotype score suggests that the patient would benefit from adjuvant chemotherapy. In the ABC combined analysis, patients with node negative HR+/HER2- cancers actually did worse...
Has the role of radium-223 changed in the treatment of prostate cancer given the availability of newer anti-androgen medications to treat metastatic prostate cancer?
Radium-223 remains a valuable palliative therapy for men with symptomatic bone metastatic prostate cancer. As we utilize abi/enza/daro/apa with ADT earlier in the mHSPC or M0 CRPC settings, the number of available and effective treatments in the mCRPC diminish. I do not recommend radium-223 with abi...
When would you consider adding adjuvant PARP inhibitor in a young gBRCA mutated patient with HR+,HER2- early breast cancer?
At this time, I would only consider this in the setting of a clinical trial, such as OlympiA (NCT02032823), given that this strategy has not yet been proven to improve outcomes in the early stage setting. These agents are very promising in the neoadjuvant setting, as highlighted by a small pilot stu...
Will you consider additional capecitabine in a patient with TNBC, residual disease after neo-adjuvant chemo, before getting adjuvant pembrolizumab or placebo on SWOG 1418 clinical trial?
We offered adjuvant capecitabine to our TNBC patients with residual disease after neoadjuvant chemo prior to enrolling them on our adjuvant immunotherapy clinical trials.
How soon after ChemoRT for a head and neck cancer can you safely initiate esophageal dilation?
I don’t know of an agreed upon time interval. I would allow for resolution of acute effects, probably 2-3 months.
How do you manage androgen deprivation in a patient with oligometastatic prostate cancer in which the primary and all known metastatic sites have been treated with curative intent radiation and PSA remains undetectable?
A great question and one that we don't have data for yet! In the absence of data, we can fall back on what we know about prostate cancer and its response to radiation and hormonal therapy, and remember the goals of treatment. Studies in the localized setting combine ADT with RT for 3-26 mo, with len...
Do you offer induction chemotherapy for patients with cT4N0 laryngeal cancer who decline surgery and are not candidates for high dose cisplatin-based concurrent RT?
any curative intent treatment with cisplatin would be high dose. are they not candidates for cisplatin or RT? If renal issues and not candidates for cisplatin, would go with carbo/taxol or cetuximab with definitve RT If not candidate for RT, would go with palliative intent chemo+immunotherapy
Are there any histologic subtypes of ER+, HER2- breast cancer that you would omit adjuvant endocrine in?
I agree that low grade, stage I, 'rare, less aggressive' histology has a great prognosis vis-a-vis distant metastasis. But, my decision on adjuvant endocrine therapy will not be based on just the histologic subtype. In other words, I would factor in traditional prognostic factors in deciding therape...