Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How does genomic profiling/next-generation sequencing assays influence your treatment recommendations in metastatic breast cancer?
At the current time, there are no evidence-based, FDA-approved or NCCN-recommended uses of genomic or protein-based assays other than ER, PR, or HER as well as gene expression profiling results like the 21-gene/Oncotype or 70-gene MammaPrint assay for routine management of breast cancer. There is no...
What factors influence your decision regarding whether to administer a dose-dense chemotherapy regimen in the adjuvant setting to patients with hormone-receptor postive disease?
Many of the studies included in the analyses treated ER+ cases that we would call lower risk using modern genomic testing with adjuvant chemotherapy. So the observed effect of chemotherapy on recurrence and OS in ER+ disease can vary from study to study, depending on the numbers of low vs high risk ...
Do you consider FOLFIRINOX dose adjustments for elderly patients with a good performance status in the neoadjuvant setting for resectable pancreatic adenocarcinoma?
This is a question worth revisiting in light of recent data. The question assumes that we would prefer to use FOFLIRINOX as peri-operative treatment in resectable PDA and this is commonly the case based on extrapolation from cross-trial comparisons of randomized data evaluating combination therapy i...
How would you approach local therapy (surgery or RT) in a patient with radiographic complete response after chemoimmunotherapy for non-small-cell lung cancer?
Only 1/96 patients (0.6%) of patients on CheckMate 816 had a complete response by RECIST so I don't think our current paradigms are really driving these kinds of responses. Additionally, there is clearly a disconnect between clinical response rates by RECIST (0.6%) and pathologic complete response (...
How do you approach a metastatic mixed non-seminoma germ cell tumor s/p orchiectomy and chemotherapy with normalization of tumor markers and persistent multiple lung metastasis (>1 cm) that cannot be fully resected?
The first question I would ask is, does he have residual radiographic abnormalities in the retroperitoneum? If he does and it hasn't been done yet, I would go to a proper post-chemotherapy RPLND as the first step. The second question is whether we should perform any biopsy of the lung nodules to pat...
How would you manage a patient who developed stage III melanoma while receiving cemiplimab (cycle 10) for locally advanced cutaneous squamous cell carcinoma?
That depends on whether you want to manage the stage III melanoma in the adjuvant vs neoadjuvant setting. If adjuvant, can likely continue cemiplimab (off-label for melanoma) as it has the same MoA as other anti-PD-1 ICI. If intending to manage stage III melanoma in neoadjuvant setting, consider swi...
Do you utilize ctDNA-based MRD testing after frontline chemotherapy for DLBCL?
I do not, as part of the standard of care, in part because of limitations of the ClonoSEQ assay in this setting, and in part because of a lack of clarity around how best to manage a positive. However, there are a number of sophisticated clinical trials exploring this question prospectively, with a f...
Do you utilize ctDNA-based MRD testing after frontline chemotherapy for DLBCL?
I do not, as part of the standard of care, in part because of limitations of the ClonoSEQ assay in this setting, and in part because of a lack of clarity around how best to manage a positive. However, there are a number of sophisticated clinical trials exploring this question prospectively, with a f...
How would you treat a stage I fully resected double hit DLBCL?
In patients with fully resected DLBCL, I still give chemotherapy. That also applies to double-hit lymphomas. Limited-stage DHL does not seem to have a poorer prognosis than non-DHL, and intensive regimens do not make a difference. I would treat with RCHOP x 3-4 cycles. Torka et al., PMID 31945157 Lu...
How would you treat a stage I fully resected double hit DLBCL?
In patients with fully resected DLBCL, I still give chemotherapy. That also applies to double-hit lymphomas. Limited-stage DHL does not seem to have a poorer prognosis than non-DHL, and intensive regimens do not make a difference. I would treat with RCHOP x 3-4 cycles. Torka et al., PMID 31945157 Lu...