Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there adequate evidence for the use of PARPi in combination with ARSI for BRCA+/HRR mutated mCRPC as compared to sequential therapy?
This question is phrased perfectly: the important consideration is whether sequential therapy would be just as good, i.e. the "old" standard of care. Unfortunately, this is not how the three trials cited above were designed. Control-arm HRRm patients were assumed to have access to PARPi post-protoco...
How are you choosing between ipilimumab/nivolumab versus platinum/pemetrexed for unresectable epithelioid mesotheliomas?
Although the combination of ipi/nivo has been approved for all unresectable mesotheliomas, the benefit was much more impressive in the NON-epithelioid histologies. Therefore, for patients with epithelioid mesothelioma, I follow the NCCN recommendations where I would discuss both platinum/pemetrexed ...
Would you consider neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer who are cisplatin-ineligible?
We have level 1 evidence supporting neoadjuvant cisplatin-based chemotherapy followed by cystectomy, there is no evidence supporting non-cisplatin based chemotherapy. Patients unfit for cisplatin should proceed directly to surgery.
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...
When do you start adjuvant radiation with areas of delayed wound healing after reduction mammoplasty?
Great question. I have cared for many patients with delayed healing post-lumpectomy (e.g., from infection, wound failure, etc.), and that experience is likely pertinent to the mammoplasty setting. Once the wound is open, it is going to take many weeks/months to “fully” heal, and it is not practical...
How do you manage a delayed cutaneous reaction to docetaxel after the first cycle of adjuvant TC in early-stage HR-positive, HER2-negative breast cancer?
There is excellent guidance in the literature on management of drug-induced rashes in these patients in Sibaud et al., PMID 27550571. Management generally involves topical and if necessary systemic steroids. I particularly like using lotion versions of topical steroids such as triamcinolone as they ...
Would you consider restarting IMID therapy in a patient with recent stroke while on IMID?
This is a very good question, and practice likely differs across institutions as data is limited. The discussion below refers primarily to the immunomodulatory (IMID) agents lenalidomide and pomalidomide.As you are aware, IMID therapy is known to be associated with an increased risk for venous throm...
When would you offer post-operative concurrent chemoradiation in anaplastic thyroid cancer?
The management of ATC has evolved considerably over recent years with the most significant being a dichotomy of management based on Braf mutation. We typically offer postoperative XRT, including in patients with either a limited or stable DM disease. However, in a multidisciplinary setting, there so...