Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you sequence Pluvicto vs docetaxel in a fit, chemotherapy-naïve patient with high-volume PSMA-avid mCRPC progressing on an ARPI?
I generally favor starting with docetaxel, though both are reasonable options. CCTG Study PR21 did not show a difference in radiographic progression-free survival between starting with docetaxel versus starting with Pluvicto in this setting. However, OS favored patients who started with docetaxel, a...
What are the treatment options for a patient with unfavorable intermediate risk PCa who desires future child bearing?
The best option for such patients would be sperm banking prior to treatment, whether they undergo RT+ADT or surgery. See this prior post on this forum regarding the impact of RT on fertility. Given the expected internal scatter dose to the testes during a course of fractionated RT, it would not be s...
Given the final publication of NSABP B-51, for which patients meeting trial eligibility would you still recommend regional nodal irradiation?
The very first thing that should occur before one makes a decision about what they are going to do is to understand how the trial was designed and who was actually accrued to it. The first point is that B51 was a superiority and not a non-inferiority trial. A very related point to that is that they ...
How will the ADAURA study impact your use of adjuvant chemotherapy?
ADAURA has not and will not impact my use of adjuvant chemotherapy. Many prospective studies have demonstrated a clear significant improvement in overall survival with the use of adjuvant chemotherapy after complete surgical resection. This is standard of care for the appropriate patients. Osimertin...
Would you recommend sentinel lymph node biopsy at the time of wide excision for a 3 mm Merkel cell carcinoma of the cheek/lateral canthus?
Unlike melanoma and certainly NMSC, MCC is highly unpredictable in nature, with clinical lesion size having little clinical prognostic value. As such, it appears that SLNB is valuable in many cases for the purposes of prognosis and in determining the need for adjuvant systemic therapy and radiation....
Would you consider adjuvant immunotherapy for a patient with high-risk Merkel cell carcinoma following definitive surgical resection and adjuvant radiation therapy?
Although there is no level 1 data supporting adjuvant RT in MCC, a relatively recent meta-analysis from an Italian group (Petrelli et al., PMID 31005218) showed that adjuvant RT is associated with a 75% reduction in local and locoregional relapses versus surgery alone, without a reduction in distant...
How would you treat a young breast cancer patient with limited nodal involvement and an isolated sternal oligometastasis at diagnosis?
Although there is limited data to support this approach, I have treated similar patients with "curative intent" with respect to the RT portion of their treatment. If the sternal oligomet is in close proximity to the ipsilateral IMNs, it can be included within the partial wide tangent fields for the ...
How, if at all, does the spectrum of HER2 positivity impact efficacy of T-DXd in the frontline setting?
Multiple studies have shown that HER2 3+ disease is a predictor for exceptional (long-term) response to first-line THP, and conversely, patients with HER2 2+/FISH positive disease are less likely to experience an exceptional response to THP. While I have not seen a subset analysis by HER2 2+ vs 3+ p...
Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?
The standard approach for patients with locally advanced esophageal cancer would be to proceed with surgical resection after neoadjuvant chemoradiation, regardless of clinical response. And then, if surgical pathology confirms residual disease, to proceed with adjuvant nivolumab. If the clinical res...
Would you consider perioperative antifibrinolytics for mild factor 7 deficiency undergoing surgery?
I do use antifibrinolytics in factor VII deficiency; however, it depends on the specifics of the surgery (i.e., mucosal surface surgery, sequelae of bleeding should it occur - spine vs oral), the patient's bleeding history, and the factor VII level. Here, I wonder if the original diagnosis was corre...