Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there strong evidence to use TMB found in circulating tumor DNA to guide the use of ICI in metastatic colon cancer?
The benefit of immunotherapy for patients with high TMB was demonstrated in the KEYNOTE 158 study (Marabelle et al., PMID 32919526). This is a phase 2 study that enrolled 1076 patients with advanced solid tumor (a total of 10 different tumor types including anal, biliary, cervical, endometrial, meso...
Will you now recommend enfortumab and pembrolizumab for most patients with metastatic urothelial carcinoma, regardless of platinum eligibility, based on the EV 302 presentation at ESMO 2023?
The data presented at ESMO were paradigm-shifting. Within the constraints of insurance coverage, I will offer EVP to all patients with untreated metastatic urothelial cancer who are otherwise candidates for this therapy.
Is it okay to send an Oncotype solely for prognostic purposes to a patient who doesn't want chemotherapy or an elderly patient with poor PS?
It isn't a matter of wrong or right in these scenarios you are asking about. Assuming they meet clinical criteria to order the test, it is more important to discuss how the patient and you would react to the prognostic information especially if it is high risk. If the patient has a clear idea about ...
How would you approach the treatment of an elderly patient with multiple myeloma and CALR+ myelofibrosis with elevated platelets?
Thank you! This is a great question and a very complicated case. Generally, I would be less concerned about thrombocytosis. I would focus more on the symptoms and splenomegaly that the patient may be experiencing. If they are not having significant MF-related symptoms or splenomegaly, then observati...
Would you recommend off-label use of chemoimmunotherapy for metastatic anal squamous cell cancer?
Anal canal squamous cell cancer (SCC) is a relatively uncommon disease, with approximately 10,000 new cases in the United States annually. Chemoradiation treatment is curative for a significant percentage of patients. The rate of locoregional failure was reported to be 10% to 30%, and th...
How do you approach patients with metastatic SCC of the larynx, PD-L1 <1, unable to tolerate 5-FU based chemotherapy due to grade 4 esophagitis/mucositis?
For patients with PD-L1 zero metastatic head and neck squamous cell cancers, standard of care is platinum/5-FU/Pembrolizumab for first-line management. The mucositis from 5-FU can be very difficult for patients to tolerate, so if dose reductions do not meaningfully allow for tolerability, I switch t...
Is there a role for adjuvant pembrolizumab/capecitabine in a patient with TNBC who receives neoadjuvant AC-T with residual disease found at time of surgery?
Based on CREATE-X, there would be data to support using adjuvant capecitabine in this scenario. As for pembrolizumab, there is emerging data that the benefit of the checkpoint inhibitor may be limited to the neoadjuvant setting based on the recent negative IMpassion030 trial of adjuvant atezolizumab...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
How do you approach a breast cancer patient with outside pathology returning as HER2 positive on FISH but internal pathology review showing conflicting results and HER2 negative on FISH on same sample?
I will give some thoughts but appreciate other opinions as well. First, it is important to consider the labs performing the assessment and their level of comfort/expertise in this assay (i.e. which do you trust).Next, it's important to recognize that especially in borderline cases of Her2 positivity...
What is your preferred first line therapy in well differentiated GI NET with Ki67 > 55%?
Without much detail provided here, I think understanding the biological behavior of this tumor is a key detail. For more indolent biology, you can use everolimus or SSA therapy, for example. For more aggressive disease, you would lean toward cape/tem, etoposide/platinum, or FOLFOX. An excellent trea...