Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage an adult patient status post subtotal resection of spinal osteoblastoma?
US can be helpful if performed serially. If/when there is evidence of growth, discuss ablation options with IR if feasible.
What is your preferred up-front treatment for transplant-eligible patients with primary (de novo) plasma cell leukemia?
To some extent, it really will depend on how aggressively the disease is behaving. Most PCL cases are quite aggressive and need urgent therapy. For an extremely fit individual who is usually in the inpatient setting, I opt for VD-PACE (usually the IMiD is not available quickly). I will perform a TTE...
Do you see any role for PARP inhibitors in NSCLC given the recent PIN trial of maintenance olaparib did not show significant improvement in PFS?
The short answer is yes, a role for PARP inhibition in NSCLC may still exist for select patients. The Olaparib Maintenance versus Placebo Monotherapy in Patients with Advanced Non-Small Cell Lung Cancer trial (PIN) evaluated the use of olaparib as maintenance therapy in patients who had tumor respon...
How do you consider first and subsequent lines of treatment sequencing in metastatic gastric/GEJ cancer that is both HER2+ and CPS>5?
I consider the current standard-of-care in the 1L setting to be pembrolizumab + trastuzumab/chemotherapy irrespective of PD-L1 status. In the published data for the KEYNOTE-811 study, which only includes the initial 264 patients in a planned interim analysis, about 85% of tumors were PD-L1 CPS >1 so...
How would you manage a patient with metastatic testicular cancer, NSGCT who has multiple CNS-only recurrences after prior systemic BEP and TIP?
Patients with advanced metastatic germ cell tumors with CNS recurrences, despite standard dose chemo with BEP and TIP and prior CNS XRT, represent a complicated clinical situation. These patients are almost always patients with either mainly choriocarcinoma or with initial hCG levels >100,000. Fortu...
Would you consider use of T-DXd for metastatic gastric/GEJ cancers with "HER2 low" given emerging data in the breast cancer setting?
Great -- and timely -- question. DESTINY-Gastric01, the East Asian study that led to T-DXd being approved in the U.S. and the drug being approved as 3L therapy in Japan, included 2 cohorts for Her2 low tumors. Cohort 1 consisted of IHC 2+/FISH negative tumors and Cohort 2 enrolled IHC 1+/FISH negati...
Based on results from ADAURA, in clinical practice, how likely are you to recommend adjuvant chemotherapy prior to adjuvant osimertinib for stage IIA T2bN0 EGFR mutant NSCLC?
I am unlikely to recommend adjuvant chemotherapy prior to Osimertinib. The 24-month disease-free survival for patients on Osimertinib was identical (89%) regardless of adjuvant chemotherapy administration. Unless long term data shows a significant benefit, I would not recommend adjuvant chemotherapy...
How would you treat newly diagnosed metastatic HER2 positive breast cancer with liquid NGS revealed ERBB2 L755S mutation (a marker for resistance against trastuzumab)?
Neratinib
How would you treat a patient with recurrent metastatic HCC 6 years after liver transplant for HCC?
Sadly, I have seen recurrence as far out as 10 years in these situations. Given the high risk of organ rejection (some literature report up to 40%) with immunotherapy and the lack of prospective data, I typically start patients with TKI such as lenvatinib or sorafenib depending on the provider's pre...
Should osimertinib be held prior to yttrium 90 liver directed therapy?
While not a common scenario and thus paucity of high level of incidence, I will, in principle, hold 1-2 days before the procedure and wait until a week post procedure ensuring LFTs are within acceptable range before restarting osimertinib.