Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred first-line treatment for metastatic melanoma in a patient with a class 2/non-V600 BRAF mutation?
Class II BRAF mutations have intermediate kinase activity and are much less likely than V600E or V600K mutations to respond to traditional BRAF+MEK inhibitor therapy. Targeted therapy should not be used as a front-line therapy in these patients. Immunotherapy (and immunotherapy-based front-line clin...
What would be your first-line approach to a patient with metastatic HCC with significant bleeding risk?
There is increased risk of variceal bleed with atezolizumab plus bevacizumab. Therefore, EGD is recommended in all patients. The patient can still receive the combination if on anticoagulants. If someone has high risk of variceal bleed, lenvatinib can be used as first line therapy. Lastly, single ag...
How do you manage the thickened secretions secondary to xerostomia during head and neck radiation?
I find that the management of acute effects of RT for H&N treatment is somewhat of a dark art. What works for one patient may not work for another. The thickened secretions are from acute irritation of the salivary glands and not so much from "xerostomia" during the acute phase of RT. For thickened ...
How do you manage a symptomatic primary breast tumor in a patient with metastatic disease?
It’s much harder to treat patients palliatively than to cure. The art of palliation generally requires weighing the acute and subacute toxicities of alternative treatments much more heavily and chronic toxicities less than we do for potentially curative care. It also requires assessing whether patie...
If zolbetuximab was not given in first line in metastatic gastric cancer with CLDN 18.2, would you give it with second line ?
There is no correct answer to this question, as, to the best of my knowledge, zolbetuximab has not been combined with any other regimen than a first-line fluoropyrimidine/platinum regimen.As a single agent, the drug has modest activity (objective response rate of ORR of 9% in patients whose tumor wa...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
In which patients will you consider a shorter course of adjuvant Herceptin?
At this point, I would not treat any patients with short term trastuzumab. The Short-Her study had very wide confidence intervals for non-inferiority, and there was a numerically superior 2.2% improvement in DFS in the long (standard) trastuzumab arm. Additionally, in the patients with the worst pro...
Mindful of the coming approval of abemaciclib, how would you decide between a CDK 4/6 inhibitor in either the first or second-line setting in HR-positive, HER2-negative postmenopausal metastatic breast CA?
Side effect profile is generally a good starting point since there is no head to head comparison (not will there likely be). Abemaciclib does have a higher incidence of diarrhea but also a lower incidence of neutropenia. It also has the advantage of daily dosing which can be less confusing for pati...
How does the extended PFS data (>4-year median) with taletrectinib impact your choice of frontline therapy and subsequent sequencing approach for ROS1+ NSCLC?
The newest taletrectinib data, in my mind, establishes this as my current (and preferred) first-line option for patients with ROS1+ NSCLC. With the totality of data available, I do not believe crizotinib or entrectinib has a role in the management of patients with ROS1+ NSCLC. Taletrectinib has exce...
Can AMPLIFY data be extrapolated to use of other BTKi's in combination with venetoclax or would you only ever use acalabrutinib/venetoclax in first line?
I prefer NOT to extrapolate results, given that BTKis have unique spectra of kinase activities ("kinomes"), different PK/PD properties (such as half life), different adherence rates and dosing schedules, and have different synergistic (especially in a complex immune context that we are committing to...