Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a postmenopausal patient on Letrozole who developed cataracts within the first six months of treatment?
While tamoxifen has been associated with ocular toxicity like cataracts, there has not been any conclusive or convincing connection between aromatase inhibitors and cataracts. Since the alternative to aromatase inhibitors is tamoxifen which we know may be associated with cataracts, and given the la...
Is there a role for further HER2 directed therapies after progression on fam-trastuzumab deruxtecan after a sustained initial response in patients with metastatic HER2+ colorectal cancer?
Great question, but no data (yet).The Destiny-CRC 01 study enrolled 16 patients (out of 86, 18.6%) who had previous anti-HER2 agents. All these 16 patients were in Cohort A which is HER3 IHC 3+ or IHC2+/ISH+ (total of 53 patients). In the subgroup analysis, median progression-free survival was simil...
Would you consider ALK-directed TKI for a ALK L1198F point mutation in a patient with metastatic lung adenocarcinoma after progressing through first line chemoimmunotherapy?
I would not because de novo ALK point mutations are rarely sensitizing in lung cancer. This specific mutation has been described in anaplastic thyroid cancer. From this question, it is not clear if this patient (1) had an underlying ALK rearrangement (which is the alteration we predict would be acti...
Would you consider reserving enfortumab + pembrolizumab combination as second line after progression post platinum-based chemotherapy?
In urothelial cancer, as in most metastatic solid tumors, your optimal outcome comes from up front therapy, "saving things for later" is not usually the best management approach. As noted by the good Dr. @Dr. First Last, given the info we have regarding EV 302 (press release), this regimen may becom...
What is the role for molecular agents alone for medically inoperable NSCLC who is not a good candidate for chemoRT?
If medically inoperable and deemed not a chemo candidate, my preference would be definitive RT alone using a hypofractionated approach to account for the absence of radiosensitizing chemotherapy even for patients with targetable driver mutations. The best data we currently have would then say to con...
What is your approach to bridging anticoagulation in patients with history of recent HIT?
One should not re-expose patients with past HIT to heparins. Even with remote HIT, there is a high rate of serologic recurrence (eg, Warkentin and Anderson, PMID 27114458) and while the rate of overt HIT relapse may be low with proper precautions, I have seen and published a couple of fatal HIT recu...
How would you approach an MSI-H HPV+ T2 N1 squamous cell carcinoma of the anus?
I would agree with Dr. @Dr. First Last's comments but want to add one point. Some patients with Lynch Syndrome may develop HPV+ Anal SCC and in this situation, the tumor could be dMMR (most likely) but also could be pMMR (uncommon but can happen). I am not sure if dMMR is the driver for the Anal SCC...
How do you manage patients with suspected cholangiocarcinoma that presents with biliary obstruction but has repeated negative brushings/biopsies?
This is often encountered in patients with PSC. Patients present with jaundice and biliary stricture, rising CA 19-9, and repeat ERCP with brushing/biopsies have shown no evidence of malignancy (often showed abnormal cells). Brushings have high specificity if positive (99%) but very poor sensitivity...
What is the preferred treatment for a patient with an EBV+ monomorphic PTLD (DLBCL) not currently on immunosuppressive therapy?
For patients who are candidates for an anthracycline-based regimen, R-CHOP is usually given if CD20+ PTLD. Patients whose tumors do not express CD20 are treated with CHOP chemotherapy alone. R-CHOP can lead to ~ 65% of CR (Trappe et al., PMID 22173060).
How do you approach an elderly patient (~80 years) with stage IIC melanoma post resection with oligometastatic brain lesion post intracranial resection which developed 2 years after treatment?
If I am understanding this correctly, then all known metastatic recurrence has been resected.In that case, I recommend cyberknife/SRS to the surgical cavity followed by single agent anti-PD1 therapy. Concurrent administration of anti-PD1 with SRS or GKRS is experimental at this point. There is no co...