Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred assay for assessing dabigatran levels?
The only specific assay that would reflect drug levels is the ecarin clotting time with dabigatran as a calibrator. We used to have this assay in our lab, but due to lack of use, was discontinued. The standard thrombin time is too sensitive, however, dilute thrombin time has been used. The mass spec...
Would you ever consider treatment without tissue diagnosis for a gastrointestinal neuroendocrine metastatic tumor based on a positive DOTATATE scan alone?
Tissue would be ideal, but I would treat the above scenario with caveats. The sensitivity and specificity of modern-day DOTA SSTR imaging approaches 90%. The question I would have is whether the patient needs treatment in the first place, based on burden of disease seen? Is disease behaving aggressi...
How do you reconcile data from the PATINA trial and DESTINY-Breast09 with respect to CDK4/6 inhibitor maintenance in metastatic ER+ HER2+ breast cancer?
We don't have data on using T-DXd with palbociclib concurrently, but the data from DB09 and PATINA does lead to questions about the optimal 1st line approach in ER+HER2+ metastatic disease. DB09 allowed for concurrent endocrine therapy with T-DXd + P, and the ADC was continued until intolerance or p...
Would you consider stopping nivo/ipi combination after a CR in a patient with metastatic melanoma?
Indirect data indeed suggest we can extrapolate the data on durable complete response after discontinuation of pemrolizumab. Indeed, most patients in complete response who stopped ipi/nivo combination for toxicity or any other reason in Checkmate 067 and 069 had durable ongoing complete response. Af...
For muscle invasive bladder cancer, after neoadjuvant chemotherapy with cis/gem and surgery with residual tumor and lymph node involvement, would you consider adjuvant avelumab as an extrapolation base on the JAVELIN 100 results?
I would not use adjuvant avelumab following radical cystectomy finding residual high risk disease after neoadjuvant chemotherapy. Biologically, this group has disease resistant to neoadjuvant chemotherapy, and is not akin to those with stable or responding disease following platinum therapy included...
Should we be stopping new starts of patients who can be triaged for 2-3 months like prostate cancers on ADT when significant community spread of COVID-19 is detectable in our area?
I would for those patients requiring ADT, which is the way I interpreted the question. I want to elaborate more because @Dr. First Last brought up other scenarios we should consider and he brings some more good points: Many patients could get active surveillance for a period of time before ADT is co...
When should you use single-fraction radiotherapy for spinal cord compression?
The SCORAD III trial is practice changing. But I do NOT plan to treat ALL patients with spinal cord compression with a single fraction of 8 Gy now. Here is why: SCORAD III is extremely important new study for the management of metastatic epidural spinal cord compression (MESCC) for patients with sho...
What guides your choice between prophylactic, intermediate, and full therapeutic dosing of enoxaparin in a woman with APLS and prior fetal loss with no hx of thromboembolic disease?
First, it is essential to confirm that patients meet criteria for obstetric antiphospholipid antibody syndrome (OAPS), based on the 2023 ACR/EULAR classification criteria. This includes persistently positive laboratory criteria (confirmed on repeat testing >12 weeks apart), plus otherwise unexplaine...
Should 3 years of adjuvant osimertinib be the standard of care for resected Stage IB-IIIA EGFRm NSCLC?
Since my initial response to this question, the ADAURA study has been fully published (NEJM 383:1711, 2020) and the FDA has approved osimertinib as adjuvant therapy for people with resected NSCLC harboring an EGFR sensitizing mutation. However, neither of these events has altered my opinion that des...
Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?
Though some clinicians have been exploring the idea of targeted therapy for EGFR mutant brain metastases, this has been done in the absence of strong evidence. Reasons for pushing this idea are that sometimes the lesions seem to respond, and this has been seen in some single arm studies and anecdota...