Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your treatment approach in patients with early breast cancer with axillary soft tissue involvement, with or without concurrent lymph node involvement?
We are fortunate that Mass General has recently published an excellent paper on this topic that helps give guidance (Naoum et al., PMID 37967296). As expected, axillary soft tissue involvement is a high-risk feature, and these patients are at high risk for metastatic disease. For example, if there i...
What FGFR inhibitor would you use for a patient with cholangiocarcinoma and a FGFR3 mutation?
Honestly, the response to these inhibitors with FGFR alterations beyond FGFR2 fusions is quite low in the data known to date. The initial infigratinib study had responses primarily in the fusions. Similar outcomes were seen in the first study with pemigatinib (Abou-Alfa et al., PMID 32203698). There...
What is your approach to cT3N0M0 mid rectal adenocarcinoma with clear circumferential resection margins on MRI?
This is an important issue in management of rectal cancers. It is best handled with an informed discussion and decision by the patients considering the pros and cons of initial surgery versus neoadjuvant therapy. The problem is, of course, inaccuracy of pretreatment staging, with the false negative ...
How do you follow patients with Bronchus Associated Lymphoid Tissue Lymphoma treated with 2 Gy x 2 fractions?
For patients with localized MALT lymphoma of the lung, in a distribution amenable to definitive RT, I would typically treat with 24 Gy in 2 Gy fractions. The risk of in-field progression with this dose is expected to be very low. Given the rarity of the presentation, I have only treated a handful of...
For oligometastatic NSCLC that would be otherwise considered stage 3, would you consider consolidative immunotherapy with durvalumab after definitive treatment for both the primary and oligometastatic site?
This is an excellent question and timely in light of the greater numbers of patients being referred for "definitive treatment" of limited metastatic NSCLC. I fully agree with @Dr. First Last that there are multiple reasons/justification to offer these patients IO after their "definitive therapy," in...
Do you routinely check echocardiograms on all patients who are starting TDM1?
I get an echocardiogram before starting T-DM1 in the adjuvant setting. In the metastatic setting, I follow a risk-based approach depending on comorbidity, prior treatment, and time of the most recent echo.
Would you ever hold off consolidation durvalumab in NSCLC stage III after chemoradiation if KRAS G12C mutation positive given recent concerns for toxicity with IO + sotorasib?
Depends on the PD-L1 status/co-mutations: If PD-L1 0% or with STK11 co-mutation, will not administer durvalumab.
How do you approach patients with very low risk stage IIIA cutaneous melanoma for adjuvant immunotherapy?
Although it may seem that Stage 3A is a higher stage than Stage 2B and 2C, it must be kept in mind that according to AJCC 8 criteria, 2B and 2C melanomas are thicker (with to without ulceration), and a 3A melanoma is by definition a thinner melanoma. A thin melanoma (<2mm) is called a 3A melanoma be...
How do you monitor risk of erythrocytosis from testosterone use for female to male transgender patients?
I utilize the Endocrine Society's guidelines for identifying secondary erythrocytosis secondary to gender affirming hormone therapy (GAHT) (PMID 28945902). For initial monitoring, at baseline and then every 3 month hematocrit for the first year and 1-2 times yearly thereafter is typically implemente...
How do you monitor risk of erythrocytosis from testosterone use for female to male transgender patients?
I utilize the Endocrine Society's guidelines for identifying secondary erythrocytosis secondary to gender affirming hormone therapy (GAHT) (PMID 28945902). For initial monitoring, at baseline and then every 3 month hematocrit for the first year and 1-2 times yearly thereafter is typically implemente...