Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach patients receiving neoadjuvant pembrolizumab (SWOG 1801) for melanoma with no response to systemic treatment?
There isn't a definitive answer to this question as patients without a pathologic response tend to have the worst outcomes in terms of relapse-free survival outcomes. There is no prospective data to support the change in treatment strategy from single agent to dual agent, especially in the absence o...
How would you sequence treatment of a synchronous IC1 high-grade serous ovarian cancer and cT3N1 rectal cancer?
In a patient with history of successfully treated locally advanced H&N cancer, how do you discern between a metachronous second primary locally advanced lung SCC vs. metastatic head and neck SCC?
Solitary, particularly long interval, N0-N1, treat like lung primary. Multiple lesions, short interval, advanced neck disease, likely metastases.
Would you offer adjuvant chemotherapy after SBRT for biopsy proven sub centimeter metastatic pulmonary nodule from rectal cancer?
This is a great question and a common scenario we met in the clinic. First, we need to know more about the case, for example, if the patient has synchronous metastatic disease or it is metachronous metastatic lesion; if the patient had neoadjuvant/adjuvant chemotherapy; how long of the disease-free ...
Would you offer a different ALK inhibitor to a patient receiving alectinib who had decompensation of liver function in the setting of preexisting cirrhosis?
Short answer is yes. In the pivotal phase III studies that compared alectinib, brigatinib, and lorlatinib to crizotinib in the first line setting (Peters et al., PMID 28586279, Camidge et al., PMID 30280657, Shaw et al., PMID 33207094 respectively), the risk of hepatic dysfunction (defined by increa...
How do you choose between axicabtagene ciloleucel and tisagenlecleucel in patients with follicular lymphoma for whom you are recommending CAR T-cell therapy?
This is an area of uncertainty. There are no head-to-head data to bring to bear, of course (and, if there were, you probably wouldn’t need to ask). The toxicity profile of the two cells is clearly different, with lower rates of severe toxicity with tisacel than with axicel. As neither product has be...
What is your approach to MRD testing in the frontline treatment of multiple myeloma?
Outside of clinical trials, I am not ordering MRD testing for patients in the newly diagnosed setting, regardless of transplant eligibility. While there are substantial data showing that MRD status correlates with survival outcomes (e.g., Munshi et al., Blood Adv 2020), there is a dearth of informat...
How do you manage grade 1-3A Follicle Center Lymphoma of the lower female genital tract, presenting with a cervical mass?
I would treat this with 12 x 2 Gy. Indeed, fertility preservation will be an issue here. Depending on the size of the lesion, if the ovaries can be spared, then 24 Gy delivered to the cervix/uterus may still allow for a pregnancy with a favorable outcome. Another experimental approach, if the patien...
What hemoglobin level prompts you to start erythropoietin in a patient with low-risk MDS?
Depending on the patient's symptoms and clinical context, I will either start an ESA when the patient starts becoming transfusion-dependent (Hgb < 8 g/dL) or, if the patient is not transfusion-dependent, but still symptomatic from anemia, I will start the ESA when their Hgb is < 10 g/dL. Prior to in...
How soon after CAR T-cell therapy can salvage radiation be delivered?
This is another important question. In our practice, the earliest we have treated patients is after their first post-CAR-T PET/CT at day 30. An abstract presented in an oral presentation at this year's ASTRO meeting by Dr. @Dr. First Last describes that radiation to sites of incomplete response at t...