Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you ever offer scalp cooling therapy to metastatic breast cancer patients wishing to avoid alopecia?
I routinely offer scalp cooling to such patients. I do acknowledge to patients that we do not have evidence to support scalp cooling in the metastatic setting, that the best evidence to support its efficacy is with taxane-based regimens, and that we really cannot be sure how or if scalp cooling will...
Would an STK11 mutation influence your choice of single vs combination immunotherapy in a patient with MSI-H metastatic CRC?
The presence of an STK11 mutation would not affect my decision to offer immunotherapy for an MSI-high (dMMR) colorectal cancer patient. There is mixed literature about if this might portend a better response to IO treatment (Kwon et al., PMID 32284250.) One should note that with a KRAS mutation in l...
How does avidity on DOTATATE PET impact your choice of whether to start somatostatin analogues in metastatic neuroendocrine tumors?
A negative DOTATATE scan is predictive for a lack of response to SSA therapy including Lutathera so I would not use octreotide or lanreotide for this patient and I would choose something else for treatment. (See for example Lee et al., PMID 32886441)
What, if any, adjuvant therapy would you offer a high risk (based on size, location, mitotic rate) GIST patient who is wild type or PDGFRA D842V mutated?
Unfortunately, there is no evidence that would support the use of postop adjuvant therapy for WT (regardless of the subtype) or PDGFRA D842V mutant high-risk GIST. The SOC would be close observation and consider mutation-appropriate options with measurable/evaluable disease.
How would you manage a patient with PSA relapse 10 years after salvage radiotherapy with PSA doubling time<6 months?
Depending on PSA, would image with PSMA PET - typically, will do around PSA 0.5 or higher (given most insurances will not cover multiple PETs in a short timespan, and detection rates of ~50% at PSA 0.5-1 per CONDOR). If no targetable (by XRT) disease on that, would discuss ADT given increased risk o...
Would you consider adjuvant immune checkpoint inhibitor therapy for non-small cell lung cancer patients with residual disease after neoadjuvant chemoradiation and surgical resection?
Prior radiation was an exclusion criteria for adjuvant atezolizumab in IMpower010. Also, neoadjuvant chemotherapy was not permitted and patients only received 4 cycles of adjuvant cisplatin based chemotherapy prior to atezolizumab. So this would be outside the scope of the trial. That being said, I ...
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
How do you discern whether elevated liver enzymes are from immunotherapy versus chemotherapy when a patient is on combination chemo/immunotherapy?
There is no consensus on the best method for distinguishing the cause of elevated liver enzymes in patients being treated with ICPi's when combined with various chemotherapies. Important considerations include time of onset, severity, and presence of hepatobiliary metastases. Hepatotoxicity from ICP...
Which molecular biomarkers do you favor to risk stratify patients (without CV risk factors) before and after undergoing treatment with cardiotoxic cancer treatments?
In general, troponin, NTproBNP or BNP, and lipid panel are the main biomarkers I use for CV risk stratification prior to cancer therapy. Baseline troponin and NTproBNP are primarily useful for cancer therapies that may cause cardiomyopathy or myocarditis (i.e. anthracyclines, anti-HER2 therapies, VE...