Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a patient with triple-class-refractory myeloma and cytopenias who has been collected for CAR-T, would you choose aggressive chemotherapy or a bispecific antibody for bridging?
The median time to response for bispecific antibodies targeting BCMA and GPRC5d is over a month. Usually, when we employ bridging therapy we want a much quicker response. Resistance likely doesn’t play a role here because of the short time that they are being used. I prefer to avoid VD-pace-like reg...
Would you offer adjuvant chemotherapy in a patient with MSS colon cancer who only has residual mucin left, without viable cancer cells despite no pre-operative chemotherapy, in the colon and lymph nodes?
This is a very specific question, and I would simplify the question to whether we should determine adjuvant chemotherapy based on the mucin seen in the lymph node for resected colon cancer. It would be very unusual that there is mucin without viable cancer cells in the colon cancer surgical specimen...
How would you manage a patient with mCRPC with a good clinical and >50% reduction in PSA to Lu-PSMA but evidence of radiographic progression on PSMA PET/CT?
As no guidelines exist today that incorporates use of PSMA PET to make a decision to change therapy; when changing therapy, I try to use PCWG criteria and the rationale to make a decision. My goal is to switch therapies only when there is clinical or radiographic evidence of clear progression (RECIS...
How do you approach a well controlled HIV patient with diffuse cutaneous kaposi sarcoma who failed to respond to radiation, paclitaxel and monthly liposomal doxorubicin?
Please consider using Pomalidomide 5 mg PO daily (21 days on and seven days off in a 28-day cycle). (Polizotto et al., PMID 27863194). There is significant activity in HIV-positive patients of this regimen (ORR-60%). The NCCN also endorses Pomalyst as a treatment for KS. Other than this, checkpoint ...
Do you switch therapy to sacituzumab in a patient with metastatic HR+ HER2- breast cancer who has stable systemic disease but new <1cm brain metastasis?
Not necessarily. Particularly, if this is the first CNS lesion that was detected and the patient was able to get definitive SRS therapy. In the ABC 5 guidelines for HER2+ CNS only progression, the committee did not endorse routinely changing therapy after local treatment. A similar argument could be...
How do you approach patients with locally advanced nasopharyngeal squamous cell carcinoma post induction chemotherapy with gemcitabine/cisplatin and imaging showing mild progression?
Yes. Assuming there is no distant metastatic disease now, I would continue with the plan for locoregional control (curative intent) chemoradiation with RT and cisplatin. This was the schema/regimen used in the most recent several large reported randomized studies from China/Taiwan and has been used ...
Would you offer empiric radiation for a growing mediastinal mass radiographically suspicious for thymoma in a patient who declines surgery?
If the patient truly refuses surgery, they need to undergo a core biopsy to get a tissue diagnosis due to the variety of potential histologies (ranging from thymoma, thymic carcinoma, lymphoma, germ cell tumor, primary lung tumor, etc.) each requiring distinct management strategies. Even...
How do you approach patients with unresectable pancreatic cancer on gemcitabine/nab-paclitaxel-based chemotherapy q28 days with severe neutropenia?
I always give gem-nab-pac every other week from the outset. So I rarely run into this issue, and when I do, it is easy, on a q2 week schedule, to add pegfilgrastim.
Would you still recommend bone marrow biopsy in an elderly non-transplant eligible patient with mild cytopenias if NGS from peripheral blood indicates MDS mutations?
Yes. The presence of mutations in peripheral blood is not diagnostic of MDS. The elderly can have CHIP mutations and mild cytopenias which qualify for CCUS rather than MDS. CCUS has a higher risk for progression to MDS but is not MDS by itself. Would get a bone marrow prior to diagnosing MDS and sta...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...