Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you offer adjuvant osimertinib to EGFR exon 19 deleted patients with T2N0 NSCLC treated with definitive SBRT?
Given the fairly striking benefit of ADAURA in resected patients, there likely would be a locoregional and distant control and likely survival benefit to this approach but we don't have data to support this. PACIFIC-4 is currently enrolling. Study of durvalumab vs placebo in patients with early stag...
What systemic therapy do you recommend for prostate cancer pelvic nodal recurrence on PSMA PET-CT after prostatectomy and salvage radiation?
If the LNs are not measurable on conventional imaging and can be covered in the radiation fields, then for now I treat as high risk salvage setting. Usually suggest 2 years ADT and radiation. If the LNs cannot be covered in the radiation fields, or are measurable, then would also escalate AR-targete...
When will you recommend enfortumab vedotin plus pembrolizumab as first-line treatment of metastatic urothelial carcinoma for cisplatin-ineligible patients?
This is a timely question given the US FDA approval of the pembro/EV combination on 4/3/2023. Currently, the label is for patients with locally advanced or metastatic urothelial carcinoma who are ineligible for cisplatin-containing chemotherapy. There are a variety of definitions for cisplatin ineli...
Would you offer adjuvant capecitabine to a patient with resected intrahepatic cholangiocarcinoma after being treated with neoadjuvant GAP chemotherapy?
This is a good question without a clear right answer. In the randomized phase 3 BILCAP trial (Primrose et al., PMID 30922733), the per protocol analysis showed that adjuvant capecitabine improved overall survival compared to observation alone. However, this study excluded patients who had previous c...
Would you consider chemoimmunotherapy in a patient with hormone positive breast cancer treated with chemotherapy who has progressed to triple negative breast cancer?
If the patient had treated ER+ early stage disease and the metastatic recurrence was retested to be TNBC and CPS>=10, I would treat using the KY355 regimens in the 1st line setting. If you are asking about ER+ metastatic disease that was treated as such then rebiopsied later on at progression and de...
Would you use a matched sibling donor with a germline heterozygous BRCA1 mutation for stem cell transplant?
This is a challenging question due to the lack of clarity around the risk of hematologic cancers in patients who have BRCA1 mutations if patients with Fanconi Anemia are excluded. The role of BRCA haploinsufficiency in marrow hematologic function in otherwise healthy donors is unclear. Multiple stud...
How would you approach therapy for a patient with symptomatic secondary CNS marginal zone lymphoma, but with low-volume systemic disease that would otherwise not warrant therapy?
CNS marginal zone lymphoma, or in the case of CNS involvement by LPL/WM known as Bing-Neel syndrome, is uncommon and clinically heterogeneous. Treatment approaches depend on rigorously excluding aggressive lymphoma (treated differently), the pattern of involvement (parenchymal or leptomeningeal or b...
What is the preferred initial therapy for T-cell lymphoblastic lymphoma in non-AYA, non-elderly adults?
In my opinion, there is no single best choice in this situation, but there are several reasonable options. Given how rare this disease is, I think physician comfort with a specific regimen is arguably the most important characteristic. Any attempt to identify an approach that yielded the best long t...
How do you discuss use of tamoxifen in your stage I breast cancer patients who are > 80 years old weighing in risk of VTE with benefit from adjuvant treatment?
The risk of both thrombotic events and endometrial cancer are age-dependent in general - much of this information is best interpreted from the prevention literature, where the numbers are larger, and the impacts of co-morbidities and concomitant medications are less. With tamoxifen use, both the abs...
What is your treatment approach in metastatic breast cancer with osseous metastases resulting in significant cytopenias?
Bone marrow metastases is not uncommon in metastatic breast cancer but, fortunately, it rarely causes dramatic cytopenias. So, if we come across a patient with cytopenias, we first perform a bone marrow biopsy to confirm the cause. If it is confirmed that metastatic breast cancer is the cause, then ...