Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?
This is a great question, and as always there is no one size fits all. For patients on active treatment for lung cancer such as chemoimmunotherapy, I continue to stress the importance of hand washing, social distancing, and to work on reducing wait times in the waiting room to limit exposure, etc. I...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
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.
How would you approach missed doses of fulvestrant due to COVID-19?
There is no specific guideline for this. But, as we do for patients who occasionally miss fulvestrant doses, I would try to schedule the next dose as soon as possible. Another option would be to consider an alternative endocrine therapy option such as AI, tamoxifen, which do not require for patients...
What is your preferred first line treatment option for a fit patient with non-squamous NSCLC who is PDL1 positive (1-49%) with no driver mutations?
This is a group of patients that often gets combination chemo-immunotherapy. However, during the pandemic, many institutions including my own treated patients on single agent immunotherapy (on the basis of the KN-042 study) to avoid chemotherapy-induced risks. My preference now is to discuss the INS...
Would you recommend 3 or 6 months adjuvant chemo for low risk Stage III sigmoid cancer (T3/N1), but with positive LVI and PNI?
I would recommend 3 months of CAPOX in this case. For a patient with stage III colon cancer, the presence of LVI and PNI should not influence the treatment plan.
For patients with locally advanced rectal cancer who desire organ preservation and can tolerate fluoropyrimidine but not oxaliplatin, what is the appropriate treatment approach?
For patients with locally advanced rectal cancer who desire organ preservation and cannot tolerate oxaliplatin, the appropriate treatment approach would be neoadjuvant, long-course radiotherapy combined with fluoropyrimidine-based chemotherapy. After neoadjuvant treatment, patients are ev...
What is your platelet cutoff for atezolizumab + bevacizumab in HCC in the absence of bleeding (variceal or otherwise)?
The platelet eligibility for IMBrave150 was 75K, I believe. Eligibility in the original SHARP trial was 60K, so I often consider somewhere around 60K. Although if truly no varices on EGD and no history of bleeding, I might consider down to 50K. Lower than that, I would probably think single agent ch...
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 approach a stage IIIC triple positive IDC, s/p neoadjuvant TCH and P, lumpectomy, and ALND with significant residual disease at the time of surgery?
I would use adjuvant T-DM1 for residual disease after standard neoadjuvant therapy for HER2+ breast cancer as described in this case. We have strong evidence from the KATHERINE randomized trial that adjuvant T-DM1 compared to trastuzumab that cuts recurrence risk by about 50% in this situation. Whil...