Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
With the approval of capmatinib, how would you approach a newly diagnosed metastatic NSCLC with MET Exon 14 skipping mutation?
Somatic MET mutations leading to splicing-mediated loss of exon 14 and subsequent MET overexpression are an emerging therapeutic target present in 2-4% of lung adenocarcinomas (1, 2). MET tyrosine kinase inhibitor (TKI) treatment was associated with improved overall survival in a retrospective study...
Would you treat a patient with Radium 223 for prostate cancer with mainly bone metastasis if he has a history of osteonecrosis of the jaw bone from bisphosphonate/Denosumab?
This is a good question, and one that has very little evidence to answer. Certainly there is some risk of ONJ due to radium 223 from case reports in the literature. There have also been successful palliative treatments with radium in men with bone mCRPC, despite ongoing ONJ due to bisphosphonates:Us...
What is your approach to advanced Hodgkin Lymphoma when bleomycin is contraindicated and infectious complications arise with A-AVD?
This is a very good question and a bit complicated. In patients with advanced HL, for whom 6-8 cycles of treatment would be the typical course, I try to maximize the dose intensity and density even in the face of infectious complications. That said, if a patient is already receiving growth factor su...
Would you consider any form of 'maintenance' therapy for a patient in a CR2 following re-challenge with platinum doublet for small cell lung cancer after first line chemo-IO?
There is no data for any kind of maintenance treatment. IO is continued per protocol, but after that I am not aware of any data to support maintenance therapy.
How do you clearly communicate to parents that the main purpose of a phase I trial is to find the best dose of a new drug with the fewest side effects rather than treating the patient's cancer?
Just with any communication, check first to see what their understanding is. Then, see if they are ready to hear what you have to say. Say it and then have them repeat it. When discussing trials, this conversation occurs over more than once. At the first conversation, one may be trying to lay out op...
What is your approach to maintenance therapy post autologous stem cell transplant for patients with concurrent multiple myeloma and AL amyloidosis?
The short answer is, I give maintenance for the multiple myeloma (MM) just as I would for patients with pure MM. While there is no data yet for maintenance in AL amyloid (hopefully soon, and many physicians do use maintenance in AL amyloid in patients with >=10% plasma cells at diagnosis), do not di...
What would you recommend as the next line treatment in a post-menopausal woman with hormone receptor positive, HER2 positive breast cancer, with progression on T-DM1 in combination with aromatase inhibitor?
Depending on the extent of disease and degree of symptoms and other prior therapies (e.g. she had trastuzumab and pertuzumab) prior to T-DM1, one could either choose tucatinib/trastuzumab/capecitabine—or if less ill or less heavily involved or asymptomatic with less disease, fulvestrant and trastuzu...
Would you choose a different anti-CD20 antibody in early relapsed (< 6 months) DLBCL treated with rituximab?
Unfortunately, the largest clinical trial asking the same question you pose here—does substitution of the anti-CD20 antibody in combination with platinum-based chemotherapy in relapsed/refractory DLBCL following RCHOP improve outcomes—has failed to demonstrate benefit to such an approach. The ORCHAR...
In a patient with multiple myeloma who cannot tolerate lenalidomide or bortezomib due to GI toxicity, what regimen would you choose for next-line therapy?
Often, lowering the dose of lenalidomide and/or bortezomib does help. If the patient absolutely cannot tolerate at any dose levels, then I would do Daratumumab based therapy. Start with Daratumumab/dex; if it's tolerable, one can add pomalidomide. Intolerance to lenalidomide does not mean intoleranc...
For patients with BRAF V600E positive lung cancer and recent PE/DVT, is there any contraindication to BRAF/MEK inhibitor therapy?
This is a good question and not an uncommon clinical scenario. The first question is whether the PE/DVT is attributable to treatment with MEKi or to the underlying cancer or other provoked risk factors (surgery, limited mobility, hospitalization, etc). In the phase 2 trial of dabrafenib and trametin...