Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Can CM577 regimen of adjuvant nivolumab s/p neoadjuvant chemoRT with residual disease following surgery be extrapolated to patients with R1 resection unable to undergo re-resection?
This is an excellent question and, of course, one for which there are no data. So, unburdened by data, I'm free to offer my personal opinion. I think all of us would value other comments and responses to this question as well.I think that this question also applies to those patients who achieve a cl...
How does use of adjuvant nivolumab impact your subsequent use of immunotherapy + chemo in a PDL1+ GEJ cancer with metastatic relapse?
This is an extremely important, and practical question, which, unfortunately, we have very limited data on. Clearly, more study is needed here so that we can develop more carefully tailored therapies for our patients. However, for now, my approach is primarily based on the timing of metastatic disea...
How would you manage a patient with history of follicular lymphoma treated with Bendamustine-Rituximab who now has a new FDG avid lesion that is biopsy proven CD30 positive CD20 negative DLBCL?
Certainly an unusual and challenging situation, and one that raises multiple questions. How long ago was the rituximab - is the CD20- status "true" or might it be a false-negative in the presence of blocking antibodies? Is it really totally negative or rare/dim?But taking at face value that the dise...
Is there experience/reports of using voxelotor in sickle cell patients who are Jehovah Witnesses with few crises but who have fatigue and/or dyspnea?
I would not hesitate to use voxelotor in most patients with sickle cell anemia, including Jehovah's Witnesses, if they have not responded to hydroxyurea with near cessation of acute vasoocclusive events and have continued hemolytic anemia. Voxelotor usually reduces hemolysis that results in an incre...
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
How would you manage metastatic small cell/neuroendocrine bladder cancer after response to 6 cycles of platinum/etoposide?
I would consider maintenance avelumab in patients with metastatic small cell carcinoma of the bladder achieving stable or responding disease after platinum-etoposide. Notably, the JAVELIN Bladder-100 trial that led to the approval of maintenance avelumab included urothelial carcinoma and not predomi...
Would you provide TDM1 or capecitabine for residual disease in HR negative patients with HER2 positivity based on copy number alone?
It is not clear from the question what is meant by "copy number alone." To be HER2 positive by copy number alone is a copy number equal or greater than 6.0 (unless IHC 0 or 1 + with a ratio also < 2.0, in which case the tumor is HER2 negative). If the copy number is between 4 and 6, but the ratio is...
Do you find data from phase 2 DESTINY-LUNG01 study sufficient to change practice in HER2 mutant NSCLC or is a phase 3 study still needed?
I think that phase 3 data are needed but not in the second-line setting. I think a phase 3 trial in the first-line setting of T-Dxd versus chemo +/- IO is the way to go.Based on DESTINY-Lung01, trastuzumab deruxtecan is more effective than other HER2 targeted strategies overall.
What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?
Educating clinic staff and patients/family members is key. Any reports of worsening respiratory symptoms such as worsening cough or SOB should be carefully worked up and managed. Always check for saturation at clinic visits and (actively) look for interstitial findings at every scan (the patient cou...
How do you interpret efficacy of trastuzumab deruxtecan based on HER2 mutation type and/or level of HER2 overexpression?
In the phase 2 DESTINY-Lung01 study, the majority of the HER2 mutation was at exon 20 and were insertion mutations. There were other rare HER2 alterations such as exon 19 and extracellular domain mutation in exon 8 that also responded to trastuzumab deruxtecan. Some of these patients had their HER2 ...