Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...
In which group of patients you would send for RNAseq for translocations/fusions that might be missed by NGS in advanced NSCLC?
In patients who are never/rare smokers in whom tissue NGS is negative, I would strongly consider RNAseq of a recent or fresh biopsy. You can find the occult fusion (or missed MET) in about 15% of NGS negative, TMB low cases based on this recent very nice paper from MSKCChttps://www.ncbi.nlm.nih.gov/...
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
How will you select patients with brain metastases for TTFields?
The METIS trial restricted eligibility only to patients with brain metastases from non-small cell lung cancer. Therefore, we would not be able to extrapolate these results and data to other tumor types and histologies. Indeed, a post hoc analysis of the data did demonstrate a greater impact in patie...
Would you ever consider stopping immunotherapy in a patient with metastatic melanoma after achieving a good response?
Yes, I would consider stopping immunotherapy in a patient with metastatic melanoma after achieving a good response.Data of 655 melanoma patients treated in pembrolizumab phase 1 KEYNOTE-001 study has shown 95 patients (14.5%) achieved CR after a median follow-up of 32 months. Treatment was discontin...
Given results of the RADICALS trials, is LT-ADT standard of care for salvage prostate RT?
I do not think long-term ADT is established as standard of care for salvage prostate radiation, as this would require a demonstration of improved overall survival in at least specific subgroups of patients. RADICALS-HD demonstrates improvement in freedom from metastasis as well as freedom from non-p...
How are you interpreting the early RASolute 302 trial findings (daraxonrasib) in metastatic PDAC?
This is an extremely exciting time in pancreatic cancer treatment! I note that PDAC/KRAS has a plenary this year at ASCO's Annual Meeting. The company has also put out a press release stating this is a positive study against chemotherapy with a doubling of overall survival. Of course, we all want to...
Do you recommend frontline bevacizumab with carbo/taxol in patients with advanced epithelial ovarian and BRCA mutation who will be receiving olaparib maintenance?
As shown in GOG-218, there is no apparent benefit to using concurrent bevacizumab with paclitaxel and carboplatin in the first-line setting, if this drug is not then continued during maintenance therapy. Our approach is to obtain genetic testing in patients with epithelial ovarian cancer as soon as ...