Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant immunotherapy to a patient with esophageal cancer who completed neoadjuvant chemo+RT followed by surgery a year ago?
I would not. In CheckMate 577, patients could receive nivolumab up to 4 months following surgery. In a patient who is a year out from surgery, we cannot possibly know the benefit of any adjuvant treatment. I, therefore, adhere to the clinical trial population/design.In general, I try to start treatm...
How should one manage a patient with leukocytosis and borderline detectable BCR-ABL without other clinical features of CML such as basophilia or splenomegaly?
Leukocytosis has many causes and I will assume within the context of this question that we can narrow the definition to neutrophilic leukocytosis, and that it has been persistent without evidence of an underlying infection, cancer, inflammatory disorder, significant obesity, exposure to a drug or to...
How do you manage severe thrombocytopenia due to splenomegaly and bone marrow involvement in CLL when starting obinituzumab and venetoclax?
This is a tough question without any information about the case. I am assuming the patient is untreated. For this setting, there are really three options supported by randomized phase 3 trials. Venetoclax + Obinuzumab has a single randomized phase 3 trial that showed improved progression free surviv...
Does the presence of signet ring or mucinous pathology alter your management of stage 2 colon cancer?
In general, both portend a worse prognosis. For stage II the benefit of chemotherapy is modest. I would strongly encourage considering the COBRA study if patient is stage IIA. https://clinicaltrials.gov/ct2/show/NCT04068103. Note that eligibility requires adenocarcinoma. I would do more frequent fol...
What are non-clinical trial options to treat high-risk MDS in a transplant ineligible patient, after progression on hypomethylating agents?
This is often a difficult discussion to have with patients as there are currently no FDA approved second line treatment approaches for such patients, but this remains an active area for clinical investigation. Some approaches are nicely reviewed in Dr. Santini's 2019 How I Treat article in Blood.In ...
How would you approach adjuvant therapy for a post-menopausal women with cT2 cN0 TNBC on biopsy s/p neoadjuvant chemotherapy and mastectomy who is later found to have RCB2 HR+ breast cancer on surgical pathology?
First, is she BRCA positive? If so, there is a role for olaparib in adjuvant setting (OlympiA trial). I would treat with capecitabine as per the CREATE X trial (Masuda et al., PMID 28564564). Although the subset of triple negative cancers benefited most, and the point estimate for the ER or PR posit...
Would you use encorafenib with cetuximab vs encorafenib alone as second line therapy in a patient with metastatic colon cancer with concomitant KRAS G12V and BRAF V600E mutations identified on liquid biopsy?
I would rather state this question as, "Would you use encorafenib with cetuximab or cetuximab with encorafenib plus binimetinib (triplet regimen), or cetuximab in combination with irinotecan based chemotherapy?"Based on the available data, it seems like KRAS mutation was not relevant. BEACON trial (...
What tumor-related factors help in deciding between BRAF/MEKi vs ICI in stage IV BRAF mutant melanoma patients?
Any patient who has a contraindication to ICI (autoimmune disease, transplant, etc...), I start with BRAF inhibitors, unless the patient is eligible for a clinical trial. Otherwise, I start with ICI, given the latest results of ECOG EA6134. Whether I choose combo with ipi and single agent PD1 inhibi...
What is your preferred first line treatment approach for a patient with PDL-1 high (>50%) NSCLC presenting with CNS mets?
The treatment decision and sequencing in patients with brain metastasis from non-oligometastatic NSCLC with high PD-L1 expression and no traditional actionable genomic alterations depend on size and location of brain mets as well as associated symptoms.Based on data from several prospective and retr...
Would OncotypeDx impact your decision to provide adjuvant chemotherapy for node-negative HR+ breast cancer with dermis or chest wall involvement?
While I'm tempted to use Oncotype or other genomic assays to omit chemotherapy as much as possible (and TBH, Oncotype may be more of a prognostic than predictive assay except at the very upper range - see Mitch Dowsett's examination of these assays, Buus et al., PMID 33108242), the prospective trial...