Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider adjuvant olaparib in a premenopausal female with TNBC with high risk features and germline BRCA1 mutation who achieved pCR after neoadjuvant chemotherapy?
I would not, as these patients were not allowed to go on OlympiA. Their residual risk of TNBC relapse after PCR is low so the absolute benefit of olaparib for a year (if any) is also going to be low.
Given results of the ELEVATE-RR study, would you consider use of acalabrutinib in all patients with previously treated CLL, or restrict it to certain patient populations?
Efficacy and safety are both important for evaluating new therapies. The ELEVATE-RR study demonstrated equivalent efficacy with a hazard ratio of 1.0 which indicates response duration was identical. Notably, several indications of safety were better which then would tilt the benefit to using an alte...
Does multiple myeloma become more radioresistant post transplant?
Anecdotally, I had a recent myeloma patient who developed progressive chest wall disease after ASCT and numerous prior rounds of therapy. I gave him 8 Gy in one fraction to two chest wall sites; one had a partial response before progressing months later, the second site progressed through RT with no...
In the rare setting of enoxaparin injection-induced abdominal wall hematoma in patients requiring long-term anticoagulation, what is your timeline for restarting anticoagulation?
Abdominal wall hematomas typically occur when a vessel has inadvertently been injured during injection. Timing of resumption of anticoagulant will vary with the underlying indication for anticoagulants. For a high-risk indication, eg multiple cardiac valves in patients with history of stroke, I woul...
What is your approach to the management of hot flashes in a patient who wants to use herbal medicine?
Hot flashes are so bothersome to some postmenopausal women, especially those with breast cancer in whom we discourage the use of estrogen or potentially estrogenic, that we now have evidence from randomized trials to help guide treatment. With regard to nonprescription therapies, data thus far suppo...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
Do you find ELEVATE-RR data and study design compelling to start preferentially using acalabrutinib over ibrutinib?
The inferiority design of the ELEVATE-RR included a 1.429 margin, but the hazard ratio between treatments was 1.0 as related to DFS and 0.82 (favoring acalabrutinib) for OS. This improved OS likely is reflective of lower cardiac events and other adverse events. To me, this is sufficiently beneficial...
Would you recommend induction chemotherapy such as TPF to a patient with locally advanced sarcomatoid carcinoma of the nasal cavity?
Sarcomatoid carcinoma of the nasal cavity is a very rare entity. There are no studies to guide optimal management. Literature support is mostly in the form of case reports. TAX-323 and TAX-324 studies did not include this histology. In general, sarcomatoid cancers are best managed by surgery (ideal...
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
How would you treat a patient with stage 4 NSCLC with EGFR R776H mutation?
R776H is a rare exon 20 point mutation. Preclinical models suggest that it is an activating mutation and that it is sensitive to erlotinib, afatinib, and osimertinib [Kohsaka et al., PMID 30404555]. Several case studies of patients with rare EGFR mutations have reported responses to EGFR TKIs (erlot...