Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adjuvant chemotherapy for concurrent early stage NSCLC in ipsilateral separate lobes, or do you consider them as separate primaries?
This situation can arise when a patient undergoes lobectomy for primary lesion but has sublobar/wedge resection of a separate nodule in a different lobe with pathology showing the same histology. If both are very early stage and no nodal involvement or other indications for adjuvant chemotherapy, I ...
Would you start neoadjuvant treatment with immunotherapy or BRAF/MEK inhibitors in a patient with a large regional inoperable BRAF V600E positive melanoma (IIIC)?
I prefer to start with BRAF inhibition, as the response rate is quite high, then ask the surgeon to complete the surgical resection after 3 to 6 months of therapy if the patient has a response, and usually offer adjuvant immunotherapy afterwards. If the patient does not respond, I would switch to ip...
How would you manage a patient with history of clear cell RCC >4 years ago who has a solitary oligometastatic brain lesion that is asymptomatic and too small for stereotactic radiation?
I've not encountered a CNS lesion too small for SRS. Sometimes, very small abnormalities are uncertain and are watched, but usually, they are big enough to be diagnostic and treated. If that's the only site of disease, I would do SRS then observe that patient.
Do you offer surveillance brain imaging for patients with EGFR+ NSCLC, stable systemic disease on TKI, and no history of metastatic brain disease?
There are very few data based on randomized trials but we know that the brain is a major site of progression even with osimertinib so I get a brain MRI every 6 months.
How do you approach the pharmacologic management of cancer-related fatigue?
After the above considerations mentioned in the question, management considerations regarding cancer-related fatigue depend on the stage of disease (advanced/metastatic disease vs not) and whether the patient is on active cancer therapy. For both groups, non-pharmacologic interventions have the high...
What maintenance treatment would you recommend for Ph positive ALL following Hyper-CVAD, transplant eligible or ineligible?
While ABL kinase inhibitors (TKIs) are commonly recommended as maintenance post-transplant in Ph+ ALL, the data supporting this practice are relatively soft. Position statements from expert panels convened by EBMT (Giebel et al., PMID 27309127) and ASTCT (DeFilipp et al., PMID 31446198) both general...
How do you approach B-cell lymphoblastic lymphoma (without bone marrow involvement) in older adults (>65-70 years)?
Lymphoblastic lymphoma is more commonly (probably 90-ish%) of T lineage, so this is a relatively rare presentation of an already rare disease. Regardless of age and distribution of disease involvement, B lymphoblastic lymphoma is typically treated with ALL regimens. However, this guidance is less he...
Would you recommend adjuvant therapy for a patient with intraheptic cholangiocarcinoma with an isolated metastasis who has undergone complete surgical resection and is NED?
Given M1 disease, I would absolutely give adjuvant therapy. Data is of course strongest with 6 months of Capecitabine, but given that you could consider this patient metastatic, it would not be wrong to give 6 months of gem/cis. I would also absolutely profile with NGS, to be prepared for recurrence...
Would you avoid the use of a TNF inhibitors in patients with a remote history of melanoma, including those with ocular melanoma?
Clinical trials of TNF inhibitors have identified a small but increased risk of malignancy with the use of TNF inhibitors, and most, but not all, of the follow-up studies done with real-world registries have confirmed this. These registries are of course sometimes affected by the behavior of physici...
Would you add tucatinib to systemic therapy for ER+ HER2+ metastatic breast cancer, where there is systemic control but new brain metastasis?
The patient has progressive disease in the brain, which will require treatment -- the standard of care option would be local therapy in the form of radiation +/- surgery. Data from HER2Climb suggests that the combination of capecitabine + tucatinib + trastuzumab controlled disease in the CNS for 9+ ...