Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you counsel an early stage breast cancer patient with lupus regarding decisions on radiation?
The data with lupus and RT is not consistent and most recent data suggest good tolerance to breast RT. I have them continue on medication for lupus and counsel them that acute morbidity and late effects appear to similar although there is some chance it may be enhanced but not contraindication to RT...
How would you approach an elderly patient with early stage TNBC with node negative disease?
While patient age, comorbidities, and T stage could influence my recommendations, if I felt that the patient was in good enough shape to tolerate chemotherapy and that her risk of distant recurrence was high enough to warrant treatment (relative to her life expectancy), I would favor administering w...
Would you use neoadjuvant TKI or neoadjuvant radiation for a large chest wall sarcoma with an NTRK fusion on NGS?
Although there is no data to support the "neoadjuvant" use of NTRK inhibitors in NTRK-fused sarcomas, the rapidity of response to this approach is amazing. There is also a school of thought that the use of NTRK inhibitors in NTRK-fused sarcomas affords a durable response. My experience is different....
Is there any role for radiation in the treatment of stage II nasopharyngeal DLBCL involving bilateral nasopharynx and unilateral cervical nodal involvement but without bony or nerve involvement?
The role of RT in the rx of stage II DLBCL, either nodal or extranodal in type, remains controversial with NCCN guidelines allowing for either approach. There is agreement that initial therapy should be systemic, typically R-CHOP at present. For patients achieving CR (PET-negative), we routinely use...
Does HPV-status play a role in selection of immune checkpoint inhibitors in upfront treatment of metastatic head and neck cancer?
In my practice, HPV-status in isolation does not play a role in selection of immune checkpoint inhibitors in initial treatment of recurrent/metastatic head/neck squamous cell cancer (R/M HNSCC). The current FDA approval for first-line management of R/M HNSCC is for pembrolizumab in combination with ...
How often do you monitor for pancreatitis (check lipase/amylase) while on Axitinib?
I don't routinely measure amylase/lipase on axitinib or other TKIs. In the early days of sunitinib development, lipase was measured and often elevated without clinical symptoms. This led to unnecessary other labs and anxiety. I have a low threshold to measure in the right clinical context, but frank...
What systemic therapy would you offer to a patient with metastatic EGFR exon 19 deleted NSCLC to the brain with isolated CNS progression while on osimertinib 80 mg and progressed through WBRT?
If this is isolated CNS progression, the answer will depend on the number of metastatic sites. This is worth a conversation with your radiation oncologist. If there are 1-5 sites progressing within the CNS, it may be reasonable to consider treating these with SRS (even if patients have had prior who...
How do you address logistic barriers related to blinatumomab when treating relapsed B-ALL?
This is a very challenging issue that speaks to an incredibly important aspect of delivering not only this drug but others like it. Despite the strong evidence that supports the use of blinatumomab in a variety of clinical scenarios for patients with B-cell ALL [e.g., Gökbuget et al., PMID 29358182;...
How do you handle Grade 3-4 standard infusion reactions with Amivantamab?
Fortunately, G3+ infusion reactions with amivantamab are uncommon. In the CHYSALIS phase I study which led to approval for EGFR exon 20 (Park et al., PMID 34339292), G3+ infusion reactions were only seen in 3% of patients. But grade 1-2 infusion reactions were fairly common.Infusion reactions tend t...
How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?
There are guidelines from the American Society of Hematology and The International Society of Hemostasis and Thrombosis as well as expert opinions recommending either apixaban or rivaroxaban for venous thromboembolism or pulmonary embolism in patients with BMI >40. In addition, this includes use as ...