Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What factors besides disease progression would lead you to de-intensify or change MM therapy for a patient with ongoing response?
After initial therapy (which may or may not include an autologous stem cell transplant), patients are generally on continuous/maintenance therapy with e.g. lenalidomide as the most common regimen. Most patients do well on this as maintenance. However, loose stools are probably the most common compla...
How do you counsel patients with newly diagnosed transplant-ineligible multiple myeloma on the expectations of treatment in terms of disease control, duration of therapy, monitoring and follow up?
I'm going to take this question very literally and write a paraphrase of my general explanation to patients at an initial diagnosis and treatment planning visit. Forgive me, this is long, a paraphrase of a 30-60 minute visit with a patient. I hope this will result in others sharing how they navigate...
When do you consider re-treatment with lenalidomide in later line therapy for relapsed multiple myeloma?
It is a challenging question due to the fact all studies post lenalidomide failure even in maintenance never included lenalidomide based therapy in first up to third line of therapy: such as Dara/Pom/dex, Dara/Car/dec, Elo/Pom/dex, Pom/Vel/dex … some argue that since the patient was on low dose of l...
What is your preferred adjuvant treatment option for a patient with stage III BRAF-mutated melanoma and a history of a solid organ transplantation on immunosuppressants?
What is the preferred number of cycles of CAPOX for rectal cancer receiving total neoadjuvant chemotherapy?
The treatment of rectal cancer is probably more confusing than ever before!The typical approach to “TNT” has been to give 4 months (8 cycles) of FOLFOX.The optimal duration of Capox is less defined.One reasonable option would be to aim for the same duration of 4 months. This would be ~5-6 cycles of ...
Would you consider radical prostatectomy for a young male with unfavorable intermediate risk cT3a prostate cancer and PSMA PET concerning for regional lymph nodes involvement but negative conventional imaging?
I would approach this scenario by considering two main issues. The first issue is what the probability of the patient truly having pN+ disease based on cN+ findings on advanced imaging. There have recently been two trials published from the Netherlands, PEPPER (using 68¸Ga-PSMA-11) and SALT (using 1...
How do you advise a patient with VTE on indefinite anticoagulants regarding the Ad26.COV2.S Johnson & Johnson/Janssen COVID vaccine?
The thrombotic events seen with the Ad26.COV2.S vaccine do not appear to be associated with a prior history of clotting events. It seems to be a different entity, similar to heparin induced thrombocytopenia, with clinical presentation of thrombosis and thrombocytopenia. Muir et al., PMID 33852795The...
Can adjuvant nivolumab for bladder CA as per Checkmate 274 be extrapolated for the concurrent chemoRT bladder preservation setting?
Great question. Short answer is no. Different scenario and very hard to extrapolate from the adjuvant post radical cystectomy setting. We need dedicated bladder preservation trials, e.g. S1806 and Keynote992. Recommend to accrue in those 2 large phase III trials for patients who opt for bladder pres...
In a patient with localized TNBC, how would you decide in whom to perform breast MRI prior to starting neoadjuvant systemic therapy?
In general, obtaining breast MRI prior to neoadjuvant is mainly based on the type of surgery that is planned. If lumpectomy is planned, then breast MRI should be obtained prior to neoadjuvant chemo and after neoadjuvant chemo but before surgery. If mastectomy is planned, then breast MRI does not add...
In patients with RET-fusion positive NSCLC with symptomatic brain metastases, would you consider starting selpercatinib/pralsetinib upfront or would you proceed with whole brain radiation with TKI to follow?
In general, my favored approach for a patient with asymptomatic brain metastasis (and nothing scary like big edema, midline shift, bleeding, etc) is brain-penetrating TKI, if available. This applies to EGFR (osi), ALK (alectinib), and RET (I use selpercatinib). Happily, these patients live longer. W...