Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach older patients who are not fit or frail with stage 1 favorable classical Hodgkin lymphoma?
The change in therapy for early stage HL from RT alone to chemotherapy usually with low dose consolidation RT was not because of lack of effectiveness of RT but rather because of concern for long term complications. HL cause specific survival for early stage disease treated with RT alone or combined...
When are you recommending bone marrow transplant recipients receive the SARS-CoV-2 vaccine?
The CIBMTR and EBMT data indicate a 20-30% mortality in transplant patients. Risk factors are age >50, male, and <12 months from HSCT. Unfortunately, the complexity of immunological recovery after transplant makes inferring the likelihood of response to a new vaccine formulation impossible. In gener...
Do you have any special diagnostic or treatment considerations when evaluating never-smokers with metastatic small cell lung cancer?
There is an increased risk of developing small cell lung cancer (SCLC) with prolonged exposure to radon, although not all studies have found this association in never smokers (Barros-Dios et al., PMID 22539606). It wouldn't hurt to ask if the home has been tested.I would be very interested in sendin...
What are the current official guidelines regarding COVID-19 vaccination for patients with cancer or for hematologic conditions?
There are a number of resources available to guide clinicians on these decisions. I recommend the COVID-19 Resources webpage curated by the American Society of Hematology (COI, I'm the editor of that website). https://www.hematology.org/covid-19 This website includes guidance on immunizations in the...
Would you offer immunotherapy for recurrent metastatic Ewing sarcoma if the tumor is MSI high or has high TMB?
Limited data available (e.g.from SARC 028 - Tawbi et al., PMID 28988646) does not suggest any reasonable activity of CPI in Ewing sarcoma subset. Treating the patient on a "basket trial" of TMB-H or MSI-H would be reasonable, but not as standard of care.
For a patient with H&N squamous cell carcinoma who underwent salvage neck dissection for residual disease following primary chemoradiation with weekly cisplatin, do you offer any adjuvant therapy thereafter if extranodal extension is found?
Here the situation should be clarified and can be nuanced. If the initial chemoradiation was unilateral and the relapse now in the unirradiated neck, then yes, adjuvant chemoradiation is indicated (radiation alone if frail or elderly). If that relapsed neck was already radiated then adjuvant re-irra...
Would you use neoadjuvant chemotherapy to treat a patient with NMIBC on TURBT pathology but with CT imaging suggestive of cT3 disease?
Clinical staging in bladder cancer can sometimes be challenging and not always clear. Repeat TURBT, esp. for T1 stage is a standard practice to reduce risk of under-staging, even if MP is present. CT IVP (ideally before TURBT to avoid "stranding" effect), exam under anesthesia, and TURBT may all hel...
What is your preferred second line therapy for an HCC patient who progressed after first line checkpoint inhibitor monotherapy?
After progression on immunotherapy monotherapy, assuming the patient is still eligible for further therapy and VEGF inhibition, I will move to a VEGF TKI. While the data supports the use of lenvatinib or sorafenib in the front-line setting (REFLECT and SHARP trials), I will use one of these agents (...
How do you approach patients with a history of lymphoma in remission who are in need of immunosuppressive (e.g. TNF blockers, 6MP) or other therapies (e.g. JAK inhibitors) for autoimmune disease that have been linked with the development of lymphoma?
Dierickx et al., PMID 26384356. Yes, you can resume immunosuppression (IS) safely. If rituximab can be used for auto immune disease treatment that would be perfect.The prior treatment for lymphoma if it included rituximab would have taken care of the b cell reservoir.If high risk for recurrence of l...
Would you consider pembrolizumab for a patient with microsatellite stable stage IV colon cancer with high TMB on liquid biopsy who has progressed on all standard therapies?
The Keynote 158 study demonstrated an objective response rate of 29% in patients with MSS tumors and TMB >=10 mut/MB (Marabelle et al., PMID 32919526). FDA subsequently approved pembrolizumab treatment for patients unresectable or metastatic tumor mutational burden–high (TMB-H; ≥ 10 mutations/megaba...