Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach treating a patient who refuses surgery, but has significant residual disease after chemoradiotherapy for squamous cell carcinoma of the esophagus?
IO and herceptin/perjeta/enhertu
In a patient with low risk T3N1 stage III colon cancer unable to tolerate CAPOX due to profound GI toxicity, would you switch to FOLFOX and extend to 6 months of adjuvant therapy?
While I certainly agree the problem lies with the capecitabine far more than the oxaliplatin, I would approach this patient a little differently. Consider that we are told that the patient had “profound” diarrhea, and no other toxicity (at least, none is mentioned). That would be a bit unusual for c...
For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?
Your approach to incidental thromboembolism found on the workup of malignancy should be similar to any evaluation of a thrombosis. It should be a structured approach with the following questions evaluated before deciding on long-term or short-term anticoagulation. First, one should determine the loc...
For patients with incidental findings of venous thromboembolism during workup of a treatable malignancy, how do you approach discontinuation after the treatment is complete?
Your approach to incidental thromboembolism found on the workup of malignancy should be similar to any evaluation of a thrombosis. It should be a structured approach with the following questions evaluated before deciding on long-term or short-term anticoagulation. First, one should determine the loc...
For patients with essential thrombocythemia who develop venous thrombosis in the setting of elevated platelet counts, would you continue lifelong anticoagulation even after cytoreduction is achieved?
This is a fantastic question, a true real-life scenario, with unfortunately little data to drive clinical decision making. What we do have to work with is that the combination of ASA plus anticoagulation increases the risk of bleeding, but does not decrease the risk of recurrent thrombosis in MPNs. ...
For non-metastatic MIBC patients with incomplete debulking TURBT, who are not surgical candidates for cystectomy or repeat TURBT, would you try chemoRT or proceed directly to systemic treatment?
Definitely chemoRT. I believe around 1/3 of patients on BC2001 had biopsy only or incomplete TURBT. No doubt maximal TURBT is preferred, but when it is not possible, that is not a contraindication to definitive treatment. If not a chemo candidate (though there are several options), I would recommend...
What would be your preferred dosage and schedule for leuprolide for ovarian suppression alongside endocrine therapy for the treatment of breast cancer?
I usually offer the q4 week or q12 week schedules. With lab monitoring for adequate suppression, the q12 week schedule is often preferred due to less visits to the center. Goserelin at 3.6mg q4 weeks or 10.8mg q12 weeks are usually what I use, occasionally leuprolide. Notably, even with q4 week dosi...
How do you decide on 2nd line therapy in a patient with HER2+ metastatic esophageal/gastric cancer who progresses after initial response to trastuzumab-based chemotherapy?
After progression on trastuzumab-based front-line therapy, there is at least a 30% chance that the patient will lose HER2 expression. Thus, if I am considering further HER2-directed therapy, I will typically confirm continued HER2 expression. Based on the T-ACT trial, a randomized trial evaluating c...
What is your preferred first line therapy for ROS1 rearranged metastatic NSCLC without CNS mets?
I would use entrectinib even in the absence of CNS disease. The CNS is the most common site of the progression in crizotinib treated patients. Given the known activity of entrectinib in patients with active CNS mets (intracranial ORR of 55%, median duration of intracranial response of 12.9 months), ...
Did NRG LU004 demonstrate safety with hypofractionated lung radiation and concurrent ICI?
We reported the initial safety results at ASCO in 2022 after the trial was completed in 2021. There are no DLT signal and safety concerns of combining durvalumab with radiotherapy, whether it is conventionally fractionated or hypofractionated. The manuscript is under preparation incorporating some b...