Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you recommend 3 months of chemotherapy, 6 months of chemotherapy, or no chemotherapy along atezolizumab in patients with low risk (T1-3, N1) Stage III dMMR colon cancer?
This is a good question (and a data-free zone). pMMR low-risk stage III disease can be treated with 3 months of CAPOX or 6 months of FOLFOX, based on the IDEA trial. The residual risk of relapse for this entity, after chemotherapy, is ~20%. FOLFOX for 3 months was inferior to 6 months by a few perce...
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
As the new Chair of NCCN's Prostate Cancer Guidelines, I am happy to answer this.The purpose of risk groups is not merely to be a prognostic divider, but to help guide treatment. Many systems have been developed that have greater prognostication than NCCN risk groups, such as STAR-CAP (which is supe...
How are you approaching endocrine therapy for patients with metastatic HR+/HER2+ breast cancer in light of enhanced HER2 directed treatment with either T-DXd/pertuzumab or HP/tucatinib?
This is an area without clear data. I am not entirely sure that it matters. While the S8814 trial demonstrated that sequential chemotherapy followed by endocrine therapy (tamoxifen) was the best arm, this question has not been fully addressed with aromatase inhibitors. I typically would start ET wit...
Is there any role for bisphosphonate or alternative bone-modifying agents use in SMM in the absence of other indications for its use?
The short answer is no, unless the patient has an indication like osteoporosis. Bisphosphonates have been evaluated in smoldering multiple myeloma in studies performed over 10 years ago. Treatment with pamidronate (D’Arena et al., 2011) or zoledronic acid (Musto et al., 2008) did not affect the time...
Is there any role for early stem cell mobilization and collection during the SMM phase?
Prolonged exposure to lenalidomide can affect the ability to mobilize and collect stem cells, though this is less of an issue with increasing use of plerixafor (Giralt et al., 2009). If you are going to treat with an IMD, it is important to collect stem cells after 4-6 months of therapy, similar to ...
Is there a subset of breast cancer patients who may benefit more from GnRH analogs for fertility preservation compared to others?
In the prior research and the meta-analysis conducted by Lambertini et al., use of GnRH was not associated with any group of premenopausal women doing worse from a disease standpoint. Further we now know from the Suppression of Ovarian Function with Triptorelin Trial (SOFT) that adding ovarian suppr...
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...
How do you monitor for pulmonary toxicity for patients on trastuzumab deruxtecan?
Eligibility criteria for T-DXd trials were based on clinical history and not on objective findings such as PFTs or radiographic criteria. Therefore, risk for factors for T-DXd-related ILD or other pulmonary toxicity are not at all clear, although they may emerge with larger pooled safety analyses an...
In your practice, what premedications do you use for subcutaneous daratumumab?
We administer the following pre-infusion medications 1 hour to 3 hours before the first 4 SQ infusions, and then we drop all premedications (except for dexamethasone) thereafter: Dexamethasone 20-40 mg Acetaminophen 650 mg Diphenhydramine 25 mg Montelukast 10 mg [this is not in the package insert b...
In your practice, what premedications do you use for subcutaneous daratumumab?
We administer the following pre-infusion medications 1 hour to 3 hours before the first 4 SQ infusions, and then we drop all premedications (except for dexamethasone) thereafter: Dexamethasone 20-40 mg Acetaminophen 650 mg Diphenhydramine 25 mg Montelukast 10 mg [this is not in the package insert b...