Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In the post Covid era, could the ILROG hypofractionated regimens (published as "emergency guidelines" for lymphoma) be considered as standard of care for ISRT?
In palliative settings, we have utilized hypofractionated regimens in hematologic malignancies for decades. Examples include 4 Gy X 1 for follicular lymphoma, 4 Gy X 5 for myeloma, 3 Gy X 10 for DLBCL, and 4 Gy X 2 for mycosis fungoides. In select circumstances (both before and after COVID-19), I ha...
What second-line therapy would you offer a patient with metastatic colon cancer with HER2 IHC 3+ amplification and KRAS G12D mutation whose disease progressed on FOLFOX?
This is a rare but interesting situation since HER2 IHC 3+ is only found in <3% metastatic colorectal cancer (mCRC) while KRAS G12D mutation is about 12% in the mCRC population. This combination is quite uncommon. The best evidence would be from the DESTINY-CRC02 (Raghav et al., PMID 39116902), whic...
Do you check the Duffy-null phenotype before starting azathioprine and in which patients?
I personally do not check the Duffy antigen prior to starting azathioprine. I do check TMPT levels on all patients prior to starting it to help determine initial dosing.
How would you manage a patient with HbSS and severe pulmonary hypertension on home oxygen?
This patient should be referred to a specialist in pulmonary hypertension in sickle cell disease for right heart catheterization and aggressive management of the pulmonary hypertension. As described, the patient is not a good candidate for lung transplant or gene therapy.
Do you recommend trilaciclib as primary prophylaxis for myelosuppression in certain patients with ES-SCLC treated with first line chemo-immunotherapy?
I do not routinely use growth factor support nor trilaciclib with chemotherapy or chemo-immunotherapy for people with ES-SCLC. My starting doses of chemo are usually carboplatin AUC 5 day 1 + etoposide 100 mg/m2 days 1-3, and the degree of myelosuppression and incidence of neutropenic fever with thi...
In light of the 2024 Shkreli Awards, how do you address patient concerns regarding the 240 mg versus 960 mg dose of sotorasib?
The randomized dose comparison study of sotorasib 960 mg versus 240 mg was conducted as part of an initiative from the US FDA Project Optimus, based on observations in the early phase dose-escalation study demonstrating non-dose proportional increases in drug exposure at dose levels of about 180 mg ...
What clinical and pathologic features do you use to discern whether >= 2 synchronous lung nodules, biopsy proven lung adenocarcinoma, are different primaries versus metastatic disease?
These cases are always discussed at a multi-disciplinary tumor board with a review of pathology slides from the operative specimen. In some cases, there are clearly different morphologies or levels of differentiation. These can be initial clues, but not definitive to determine synchronous primaries ...
Is there any evidence that patients with metastatic NSCLC with KRAS G12C mutations benefit less from treatment with immunotherapy?
KRAS mutation in NSCLC has been associated with improved response rate and overall survival compared to KRAS wild type NSCLC in meta-analysis of single-agent, second-line trials with PD-1/PD-L1 inhibition. Moreover, analysis of patients with KRAS lung adenocarcinoma divided by subsets including co-m...
What is your current practice for obtaining PD-L1 and mutation testing for newly diagnosed metastatic NSCLC?
PD-L1 testing is done reflexively in my institution. Molecular testing needs to be ordered by oncology. When I see patient in the initial consultation, I already have PD-L1 expression available. I strongly believe in next generation sequencing for my lung cancer patients as it preserves tissue. Curr...
Which targeted therapies should we be more cautious of giving after recent immunotherapy in NSCLC?
In general, one should be cautious. Phenomenon of increased toxicity with immune checkpoint inhibitors (ICIs) plus targeted therapies such as EGFR TKI (pneumonitis, hepatotoxicity or dermatologic toxicity), ALK TKIs (mostly hepatotoxicity) or BRAF inhibitors (hepatotoxicity, dermatologic) were obser...