Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adding durvalumab to second-line chemotherapy for cholangiocarcinoma which progressed on gem/cis alone?
Yes. Data is needed, however, a scaffold approach maintaining durvalumab and adding different chemotherapies like NIFTY or FOLFOX as walls to the building frame of immunotherapy is appropriate and justified.
What treatment would you recommend for a patient with recurrent oligometastatic abdominal leiomyosarcoma, with two liver lesions?
I would ask for needle ablation. Leiomyosarcoma is unusual among cancers in that serial oligometastatic recurrence is not uncommon. These people can be managed with serial destructive therapy - resection, needle ablation, or radiosurgery. I have met people with LMS who have had many resections and a...
How do you define bone disease progression in mCRPC while on docetaxel?
Defining bone scan progression on docetaxel is no different than in other treatment contexts and generally, I use PCWG2-3 criteria. I generally do not stop docetaxel in the first 4 cycles based on PSA changes alone since transient PSA rises followed by falls can occur during these first 3 months. Ho...
Would you offer adjuvant therapy of any kind to a patient with synchronous primary lung cancers if all early stage and curatively treated?
Personally, I would not. However, this assumes that we are convinced that these are distinct early stage lung cancers. I would advocate for NGS testing of each tumor to ensure these are not actually sites of metastases. If truly distinct early stage cancers, then would treat with surgery/radiation a...
How would you approach a T3N1M0 mid rectal cancer that is MMR deficient?
About 2.7% of rectal adenocarcinoma are mismatch repair deficient (dMMR) (Papke Jr. et al., PMID 36322852) and locally advanced dMMR rectal cancers have a great response to immunotherapy. Six months of single agent Dostarlimab led to 100% complete clinical response in the phase 2 study including 14 ...
When do you perform a kidney biopsy in a patient with AKI that is thought to be related to an immune checkpoint inhibitor?
I would wait for the response to corticosteroid therapy before the renal biopsy.
Would you drop the duration of palbociclib from 1-21 days to 1-14 days if still neutropenic with 75 mg dose in metastatic breast cancer?
I have seen various "off protocol" solutions that oncologists use, probably with the idea that "some is better than none" (which is often true but hard to know how much benefit in a data free zone). Anecdotally, I've seen: every other week therapy; 3 weeks on and 2 weeks off; and finally 5 days on w...
Would you withhold a fluoropyrimidine in a newly diagnosed patient with metastatic colon cancer who had a STEMI and new diagnosis of ischemic cardiomyopathy within the last 3 months?
While the reported incidence of cardiac events is noted above, in practice this is far less likely as a clinical event. Also, as noted, vasospasm is more likely in the younger patient, generally without atherosclerotic heart disease. In the patient with a STEMI, it is most likely safe to use infusi...
What is the appropriate management of severe myalgia during atezolizumab infusion?
Immune related adverse events involving the skeletal muscle following immune checkpoint inhibitor therapy include polymyalgia rheumatica (PMR) like syndrome and myositis. Referral to a rheumatologist is recommended for a severe musculoskeletal adverse event. Myocarditis is not addressed in this brie...
Do you repeat molecular testing at progression in gastric/GEJ tumors or is the initial pathology sufficient for entire treatment course?
As I have addressed elsewhere, yes, I would rebiopsy at the time of progression on any anti-Her2 therapy to confirm persistent Her2 positivity. I try very hard to biopsy a progressive tumor. If this is not possible, ctDNA to assess for persistent ErBB2 amplification is an option, albeit one that is ...