Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When would you use PARP inhibitors in patients with refractory metastatic castrate resistant prostate cancer with somatic non-BRCA HRD mutations?
This is a very relevant question as clearly there is major heterogeneity in the outcomes with both olaparib and rucaparib in men with mCRPC based on their underlying germline or somatic tumor genomics. In addition, prior therapy and available alternatives including clinical trials with more or less ...
What is your general approach to treatment sequencing of available regimens in castration-resistant metastatic prostate cancer?
For mCRPC, my general approach with standard agents is a next-generation AR agent (typically started in the CSPC setting), followed by docetaxel, followed by Lu-PSMA. If disease is progressing slowly and is PSA producing, I will consider a switch from a first-line to a second-line hormonal agent, ty...
What is the role of adrenalectomy in managing isolated recurrence of stage IIIc melanoma, occurring 2 years after the original diagnosis, in a patient who declined adjuvant therapy?
Is the adrenal gland the only site of recurrence? Also, is the recurrence unilateral or bilateral? Unilateral adrenalectomy will not lead to permanent adrenal insufficiency, but bilateral adrenalectomy will (the patient will end up needing maintenance steroids permanently and need to have an endocri...
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
Do you consider post-NAC isolated tumor cells in LNs to be residual disease in TNBC to justify capecitabine?
The brief answer is yes, I would. These patients were included in the CREATE-X trial (Masuda et al., PMID 28564564). Also, there is data out of Boston that following neoadjuvant chemotherapy, patients with even isolated tumor cells in lymph nodes have a poorer prognosis (Wong et al., PMID 31228134)....
What is your preferred therapy for CDK12-altered advanced prostate cancer, outside clinical trial?
CDK12-mutated prostate cancers are aggressive and typically respond less favorably to AR-directed therapies. The CDK12 gene was on the eligibility list for the PROfound study, so olaparib could be used for mCRPC patients who have progressed on at least one AR-directed agent. In the CDK12-altered sub...
What is your approach to mitigating the infection risk with bispecific antibodies in multiple myeloma?
As of June 2023, anybody who says they have a definite answer to this is misleading you. We are unfortunately learning as we go, and LOTS of loose ends to be tied up. I'd argue everybody in this setting should already be on universal VZV prophylaxis (e.g., acyclovir), and I'd also argue that most of...
Do you use endocrine therapy concurrently or sequentially with radiation therapy in hormone receptor positive breast cancer patients?
I do it concurrently for patients with high burden of disease (several lymph node positive). Otherwise, I wait as it's likely safe to postpone endocrine therapy a few weeks to after radiation therapy and spare patients concurrent side effects.
How do you choose between the different recently approved Bispecifics Antibodies for Relapsed/Refractory Multiple Myeloma?
I would pick BCMA directed BsAbs first, treat on label (weekly or q 2 week) to best response and then space out the schedule to q 4 weeks (or even q 8 weeks). Basing this on 6+ years experience of using BsAbs in FIH/PI-III as well in the commercial setting. The way to mitigate infections/AEs will be...
How will you decide who to offer ramucirumab + pembro after progression on chemoimmunotherapy?
In S1800A, overall survival benefit was relatively consistent across subgroups including TMB levels and PD-L1 strata. I would take into account the patient’s prior response to ICI (extent and duration) and the side effects from the ICI therapy. For instance, I would favor chemotherapy for those with...