Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
How do you contextualize the stage 1 results from the PRESERVE-003 trial within the current treatment landscape for patients with squamous NSCLC who have progressed on PDL-1 therapy?
The PRESERVE-003 trial evaluated gotistobart, a novel CTLA-4 antibody, compared to docetaxel in participants with squamous cell NSCLC who had tumor progression on prior platinum-based doublet chemotherapy and immunotherapy. The trial was conducted in 2 stages, and results from the first stage are av...
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 a lack of use, it was discontinued. The standard thrombin time is too sensitive; however, dilute thrombin time has been used. The mass...
What would you use as adjuvant endocrine therapy for a patient who developed an invasive, hormone receptor positive breast cancer while on raloxifene for almost a decade prior?
In this situation I would use an aromatase inhibitor if possible. One would not expect an ESR1 activating mutation to be readily detected after treatment with a SERM, since estrogen deprivation rather than receptor blockade enriches for ESR1 mutant clones.
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
Has precision medicine changed how you consent patients for treatment?
The use of precision oncology technology and genetics has changed the ability to provide informed consent. In general, the riskier or less standard of care a therapeutic intervention might be, the greater the need for informed consent. In this way, precision oncology has pushed the envelope especial...
How do you choose among the available PD-1/PDL-1 inhibitors approved for metastatic bladder cancer?
This is an evolving field. While the thought had been all the drugs were likely equivalent in efficacy (with no head to head trials) this has changed in the past week. Roche had a press release in which they announced the Phase III IMvigor211 study that evaluated atezolizumab in people with locally ...
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...
What is the longest acceptable interval between radical orchiectomy and adjuvant BEP for Stage IIB/III pure seminoma in the age of COVID-19?
Drs. @Dr. First Last and @Dr. First Last have worked with GCT experts to create practical recommendations during this pandemic. You can read these here. Briefly, these patients should be still be treated with timely curative intent. Treatment decisions will need to be individualized for each patient...