Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach following R1 resection in a patient who has received total neoadjuvant therapy for rectal cancer?
This is a challenging scenario and there is not a one-size fits all solution. My decision making would involve thorough assessment of the patient's performance status, co-morbidities, pre-treatment extent of disease, tolerance of therapy, and review of what TNT regimen was employed: number of chemo ...
Would you recommend use of ESA for anemia of kidney disease in the setting of metastatic solid tumor malignancy?
It is not unreasonable in CKD patients with symptomatic anemia and a non-curable metastatic cancer to consider using an ESA. However, this requires an extensive discussion with the patient. ASCO/ASH guidelines recommend against the use of these agents in patients with curable malignancies, so if the...
Is there a role for frontline combination therapy with a hypomethylating agent plus venetoclax for high risk MDS?
Yes, if we extrapolate from AML and based on promising phase 1b clinical trial results (link below) so far, but venetoclax is not approved for MDS as of yet. Improved CR but also increased cytopenias, dose has not been confirmed yet. https://www.ashclinicalnews.org/on-location/ash-annual-meeting/ven...
What is your approach to a patient with an EGFR exon 19 mutated NSCLC who develops progression on osimertinib and repeat biopsy demonstrates the EGFR exon 19 mutation and a new BRAF V600E mutation?
I have a couple of these patients - and the triplet combo seems to be helping them. There is really no good data to support this combination. However, the AE profile of these agents are different and combination should not increase toxicity theoretically. BRAF, MET, and EGFR are all on chromosome 7 ...
Would you offer adjuvant immunotherapy for a melanoma patient with lymphocytic colitis?
If the patient has active/symptomatic lymphocytic colitis and/or is undergoing therapy for lymphocytic colitis, I would not offer adjuvant checkpoint inhibitor immunotherapy as the risk/benefit ratio is likely to be too high. As the underlying pathogenesis of lymphocytic colitis is not entirely clea...
Do you routinely offer a bisphosphonate or denosumab to multiple myeloma patients without skeletal lesions?
Our practice is to give 2 years of bone-directed therapy in all comers. Preferably bisphosphonates over denosumab for cost reasons unless needed due to CKD or intolerance.I agree that the case is less compelling for patients without skeletal lesions at baseline. An old RCT of bisphosphonates versus ...
How do you approach less common cutaneous/mucosal toxicities from EGFR TKI and monoclonal antibody therapies, such as ocular (keratitis and conjunctivitis) and genital mucositis (vulvovaginitis and balanitis)?
I have a patient with metastatic colon ca who was on pembrolizumab for ~16 months with NED who developed grade 3 oral/upper GI mucositis felt to be an autoimmune AE after extensive work-up. He very gradually responded to high dose prednisone followed by a slow taper that took several months due to f...
How would you manage multiple myeloma with a suboptimal response to frontline quadruplet therapy?
A suboptimal response, i.e. less than PR, to 4-drug induction is likely a poor prognostic sign, I just don't know how poor. This does not mean that you should follow induction with a tandem autologous transplant, CART, or bispecific as we don't know whether it's better than just moving forward with ...
Do you think there is any compelling data to support giving brentuximab as frontline therapy for pediatric patients with Hodgkin lymphoma?
Yes and no. It is clear that you can cure patients with pediatric HL without the use of brentuximab vedotin. While I believe it is safe and effective, if it is not covered by insurance, I would not advocate for its use in low and intermediate risk pediatric patients.However, for HR pediatric patient...
In a patient with metastatic clear cell RCC who achieved a prolonged PR with first line nivolumab/ipilimumab, discontinued due to IRAEs, would you consider a TKI/checkpoint inhibitor combination regimen?
The question of the utility of IO after IO in mRCC is an important one that has not yet been adequately studied. As of now, I believe single agent VEGF TKI is standard of care in this setting (or perhaps lenvatinib/everolimus). There are some retrospective data about Ipi/nivo after prior IO with som...