Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with newly diagnosed stage IV NSCLC who has an activating mutation in the ERBB2 extracellular domain and a concurrent classical EGFR mutation?
No high-level evidence/guidelines for such a situation since oncogenic ECD mutation in HER2 itself is quite uncommon (approximately <10% of HER2 mutations [Robichaux et al., PMID 31588020]), and co-occurrence with classical EGFR mutation will be even less common. Will generally treat based on the cl...
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
Do you recommend ovarian suppression in all premenopausal women under age 35 with ER positive breast cancer based on the SOFT/TEXT data, regardless of other risk features?
I do not recommend ovarian suppression on all women under 35. Like any intervention, we need to know the absolute risks of recurrence with and without the intervention. For these reasons, given the side effect profile of ovarian suppression in younger women, I usually reserve it for women with large...
Given the final publication of NSABP B-51, for which patients meeting trial eligibility would you still recommend regional nodal irradiation?
The very first thing that should occur before one makes a decision about what they are going to do is to understand how the trial was designed and who was actually accrued to it. The first point is that B51 was a superiority and not a non-inferiority trial. A very related point to that is that they ...
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
How would you manage locally advanced, resectable gastric cancer that is MSI-H?
I would not recommend FLOT + durvalumab for MSI-H gastric/GEJ patients. I say this because there is mounting evidence that chemotherapy may not provide a significant benefit for these MSI-H patients at all (1). All efforts should be made to spare this patient population from getting cytotoxic chemot...
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...
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...
How do you talk with your patients regarding radiographic expectations on surveillance CT after lung SBRT?
In general, especially when I have a discussion about the 3-month follow-up scan and tell patients that the lesion may likely be stable in size, which is often normal, and not to panic. There may also be post-radiation changes that make it more difficult to initially interpret. I think this highligh...