Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do the results and approval based on ADAURA trial suggest a role for adjuvant osimertinib in patients with stage IIIB-C, EGFR mutant patients treated with concurrent chemoradiation?
ADAURA trial was not designed to address this issue. But that being said, we need to remember few things before considering "maintenance durvalumab" in patients with EGFR-mutant lung cancer, following chemo-radiation: 1. EGFR-mutant NSCLC patients may not derive any clinical benefit from single-agen...
What criteria do you use in deciding whether or not to treat the pelvis in prostate cancer?
NRG/RTOG 0924 - The end of elective nodal RT in localized prostate cancer? Top line results: NRG/RTOG 0924 is a very large phase III randomized trial powered for overall survival (OS) to determine if there is a benefit of the addition of whole pelvic radiotherapy (WPRT) to prostate RT plus ADT. This...
What neoadjuvant therapy would you choose for a post menopausal woman with ER negative, PR positive high grade node negative breast cancer?
Assuming that there is no reason to doubt the results of the hormone receptor testing, and her HER2 is negative, I would treat her the same way I would a triple-negative cancer—I would not bother to send Oncotype as it should be high with the negative ER, and I wouldn't believe it if it came back lo...
How long do you treat with IMID in a case of smoldering multiple myeloma?
I have not yet adopted use of lenalidomide for SMM, as I believe in the future, we will do away with the definition of SMM—patients either have MGUS which is observed, versus MM which requires the standard platform of myeloma treatment. This will be accomplished with a better molecular understanding...
Would you supplement iron for low iron studies in absence of anemia?
The answer is absolutely and positively. Iron deficiency causes symptoms independent of anemia which include fatigue, brain fog, restless legs syndrome, and pagophagia and other forms of pica. You simply cannot dignify waiting for overt iron deficiency to develop in someone with symptomatic iron def...
Would you prioritize TACE or systemic therapy in BCLC B multifocal HCC with tumor bulk higher than "up to 7?"
This is a challenging area where we need more definitive studies. With the info available, I do favor systemic therapy for such patients. Liver directed therapy is unlikely to lead to adequate control for such multifocal disease and the patient is likely to require multiple treatments to different a...
In light of the pending overall survival data and reported declines in quality of life associated with the PSMAddition trial, how do you envision incorporating Pluvicto into the management of mHSPC?
The PSMAddition trial was a phase III trial of [177Lu]Lu-PSMA-617 (i.e., Pluvicto) combined with androgen deprivation therapy (ADT) plus an androgen receptor pathway inhibitor (ARPI) in patients with PSMA-positive metastatic hormone-sensitive prostate cancer (mHSPC). This trial randomized men with u...
How do you stage patients with testicular cancer who may have CSIS disease?
This always looks easy, but you have to be careful and have patience. Some mistakes occur because providers use the PRE-orchiectomy markers or immediate post-orchiectomy markers before they have a chance to normalize. Also, providers sometimes react to low abnormal stable markers which often are fal...
Is there a role for DDR gene mutation or tumor mutation burden/load in predicting response to immunotherapy in urothelial cancer?
Our recent work showed that urothelial cancers harbor high rate of alterations in DDR (DNA damage repair and response) genes, with 25 – 29% rate of deleterious alterations and up to 25% with variants of unknown significance – considering the genomic complexity of urothelial cancers, it is not un...
How do you approach adjuvant chemotherapy in patients with resected pancreatic adenocarcinoma?
For my good performance status patients, I offer gem/cap as per the ESPAC-4 trial. Though the incremental benefit is modest, it was statistically significant and the toxicities associated with the combination are quite manageable most of the time. I look forward to the results of three other adjuvan...