Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with limited/resectable metastatic melanoma and no evidence of disease after resection, when would you consider doublet immunotherapy rather than nivolumab or pembrolizumab monotherapy?
This is an interesting question. I would say the standard approach would be to use anti PD1 alone. There was an interesting trial presented at ESMO 2019, the IMMUNED trial, that was a phase 2 randomized trial comparing the use of combination ipilimumab and nivolumab compared to nivolumab alone for r...
Would you consider the use of PARP inhibitors in patients with BARD 1 mutation and refractory pancreatic cancer?
I will use it.In a disease like pancreatic adenocarcinoma, where treatment options are so limited, one has a much lower threshold to think out of the box. Of course there is no good (or any) data on the use of PARPi in this particular setting. However, with the manageable toxicity of the PARPi, I wo...
Would you offer adjuvant TKI to patients with locally recurrent multifocal adenoid cystic carcinoma?
I would not give a TKI in the adjuvant setting following a local recurrence that was resected. The only data that we have with these agents are in the setting of metastatic disease. The likelihood of recurrence, I believe, would be quite high once the agents are stopped, as we do not know how long o...
For a patient with HER2+ breast cancer with progressive but asymptomatic disease in the brain, would you hold off on WBRT to do a trial of tucatinib, or proceed with WBRT then tucatinib?
The trial allowed both treated and untreated brain mets, and showed response rate and improved survival. If the patient is not a candidate for SRS, it’s reasonable to watch brain lesions with serial MRIs.
What is the appropriate concurrent chemoradiation regimen to treat unresectable stage IIB lung adenocarcinoma?
Historically, many locally advanced NSCLC trials have included patients with unresectable stage II disease. While those patients comprised only a few % of the study population, I think it is largely reasonable to extrapolate findings from stage III NSCLC patients to patients with unresectable stage ...
What would be your first-line approach to a patient with metastatic HCC with significant bleeding risk?
Single agent nivolumab or pembro.
Would you offer salvage chemotherapy to a patient with stage IIIC poor risk NSGCT in whom AFP fail to normalize even after 2 months of completion of 4 cycles BEP?
It depends on the absolute value and the trend of elevated AFP. Low level AFP elevation (usually in the teens) is common and difficult to accurately interpret the abnormality. If the AFP is not rising, I probably proceed to post-chemo RPLND as the first step. Also, sometimes people proceed to chemot...
Is there a role for maintenance lenalidomide after non anthracycline regimens in elderly patients with DLBCL?
Lenalidomide maintenance prolonged PFS among elderly patients with diffuse large B-cell lymphoma who had achieved partial or complete response to standard therapy (RCHOP), according to results of the phase 3 REMARC trial. It did not translate into OS advantage in the experimental arm. I would discus...
Would you use a NTRK TKI for a patient with metastatic HR+, HER2- breast cancer with a complex NTRK3 gene re-arrangement on Foundation testing?
While it's difficult to give an answer without knowing details of the fusion event, I would point to the potential for immunohistochemistry for Trk as an orthogonal method for identifying Trk expressing cancers with potential for testing Trk inhibitors. I would point to this paper for further inform...
Do you change systemic endocrine therapy for a patient who progresses only in the brain after SRS for metastatic HR+ breast cancer?
No, I would continue the same hormonal therapy until systemic progression. The brain is a sanctuary site. Disappointing that abemaciclib did not prevent since it crosses b-b barrier.