Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How long would you continue trastuzumab for a patient with metastatic HER2+ esophageal adenocarcinoma whose tumor has achieved CR with FOLFOX + trastuzumab and has been disease-free for nearly 3 years?
This is an important question and one that we are thankfully much more likely to have to address than ever before. I think that slightly more contemporary iterations of this question can be asked for a patient with a Her2 positive, PD-L1 CPS >1 tumor who has received pembrolizumab/trastuzumab and FO...
Is there still a role for mTOR inhibitors in metastatic RCC in the immunotherapy/TKI era?
Practically all my patients with metastatic clear cell RCC will receive an mTOR inhibitor at some time during their treatment course unless they achieve durable CR with early therapy lines. It is a plausible pathway to target, often well tolerated, and very rarely (one in hundreds) may produce durab...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
This would be an unusual presentation for marginal zone lymphoma (MALT lymphoma) and not one I've actually encountered. In a large series from MSKCC, "soft tissue/bone" comprised 2% of cases treated with radiation therapy (IJROBP 2015;92:130). Case series from Princess Margaret (Cancer 2010;116:3815...
Would you recommend PARP inhibitor maintenance for a patient with HR-proficient ovarian cancer with no targetable mutation, but with a favorable KELIM score and a significant clinical, radiographic, and serological response to platinum-based chemotherapy?
To date, the clinical trials that have included biomarkers for response to PARP inhibitors have shown that those with BRCA pathogenic variants appear to have the largest benefit followed by those with HRD tumors; however, these do not account for all the individuals who have disease that could benef...
With immunotherapy now often being used in the first-line setting for advanced endometrial cancer, what is the role of immunotherapy in the second-line?
This is a relevant and important question that we have yet to definitively answer. Furthermore, it may depend on several factors such as progression while receiving front line maintenance immunotherapy versus progression after completion of maintenance treatment, or progression after discontinuation...
In patients with HCC and asymptomatic but endoscopically visible varices, how long do you wait to start bevacizumab after banding?
That is an excellent question and one that does not have a clear answer to date. In these situations, timing of bevacizumab initiation depends on the patient's risk of bleeding and often is a discussion between oncology and a skilled endoscopist. We typically wait ~3-4 weeks after an intervention fo...
How would you treat a potentially resectable stage III lung adenocarcinoma with an EGFR mutation?
How would you treat a potentially resectable stage III adenocarcinoma with an EGFR mutation? Do you consider any neoadjuvant therapy or proceed to surgery followed by adjuvant chemotherapy and osimertinib? This is a very challenging patient scenario that we face with some frequency and it truly is l...
Would you anticoagulate a patient with splenic infarctions in the setting of CMV viremia?
Based on my general knowledge/experience, I would consider CMV viremia as temporary, short-lived risk factor for a thrombotic event on a part of other inflammatory conditions, and outside of other indications for anticoagulation (e.g., atrial fibrillation, etc), my inclination would be to conclude ...
How do you treat newly diagnosed multiple myeloma with 1q gain?
There is still a lack of randomized phase 3 data demonstrating that KRD is superior to VRD for patients with high-risk cytogenetics. However, the recently presented ENDURANCE study only excluded t(14;20), t(14;16) and del(17p) and did include +1q (ASCO 2020 LBA3). The investigators did not report on...
Does the presence of asparaginase antibodies on Granger Genetics testing indicate need to switch asparaginase formulations?
I would rely on the serum asparaginase activity (SAA) assay rather than the antibody testing. SAA has proven to be a reliable predictor of asparagine depletion and is a widely acceptable method for therapeutic drug monitoring. On the other hand, asparaginase antibody testing has not been consistentl...