Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you give a fit <40 year old with T3N1b low risk Stage IIIB colon adenocarcinoma 6 months of adjuvant chemo or feel comfortable limiting to 3 months of CAPOX?
For T3N1 disease, 3 months of therapy with oxaliplatin and fluoro-pyrimidine is non-inferior to 6 months. Statistically equivalent with an upper limit of 95% CI <1.12. Furthermore, on retrospective subset analysis (choice of FOLFOX or CapeOX not randomized), 3 months of CapeOX was superior to 6 mont...
How do you now approach treatment sequencing in MM in light of the DETERMINATION trial data?
There are two questions that come to mind re: DETERMINATION with respect to sequencing.1) To do early transplant or not?2) To do indefinite lenalidomide maintenance? My views on question #1 are evolving, but here is how I have unpacked it and stated elsewhere on theMednet. REASONS TO DO TRANSPLANT: ...
How do you approach continuation versus cessation of systemic therapy for patients with stage IV triple negative breast cancer with a prolonged complete response to therapy and who are tolerating therapy well?
This is a difficult question to answer. Prior studies in metastatic breast cancer that tested chemotherapy holiday showed inferior survival as compared to maintaining or attenuating systemic therapy (examples: Coates et al., PMID 3683485; Stockler et al., Breast Cancer Research and Treatment 2003; J...
Do you hold or avoid pemetrexed in patients with NSCLC and pleural effusions?
I do not. Given pemetrexed's relationship to methotrexate as an antifolate, the question has come up of whether the same precautions taken with methotrexate regarding effusions/third space fluid are necessary for pemetrexed. Thankfully, this does not appear to be the case, as several studies (here i...
In someone with an asymptomatic JAK2 V617 mutated and BCR/ABL negative MPN with a steadily rising WBC, when do you decide to start cytoreductive therapy and which agent(s) do you recommend?
First, let's abandon the phase "BCR/ABL-negative MPN". This is an oxymoron because BCR/ABL can be expressed in a JAK2 driver mutation-positive MPN. In fact, both BCR/ABL and JAK2 mutations can be expressed in normal individuals at very low levels without causing disease. Both mutations can also be p...
Outside of a clinical trial, what is your preferred third-line systemic therapy option for a patient with relapsed/refractory ES-SCLC?
That will depend on what the patient has received in the second-line setting. If the patient has good PS, the NCCN recommends one of the various options. You could try either topotecan or lurbinectedin, whichever was not used in the second-line setting.
What are your top takeaways in Gynecologic Cancers from ASCO 2022?
1. ATHENA (LBA5500)- Consistent efficacy signal with PARPi maintenance therapy in the front line- Another potential option for our patients with greater dosing flexibility- The BICR PFS difference in the HRP population really caught my attention. Nearly a 6 month improvement with median PFS in the r...
What is your institutional approach to a restrictive “neutropenic diet”?
Simple answer: never. The "neutropenic diet" has no efficacy and may actually be nutritionally AND microbially inferior to normal diet. This has been shown by multiple studies. I like the title of the review, "Things We Do For No Reason: Neutropenic Diet." Ma et al., PMID 35356218. Radhakrishnan et ...
Are there differences in efficacy of ramucirumab + pembrolizumab based on extent and duration of response to first line chemo/pembro?
S1800A required that patients have at least 84 days (~4 cycles) of time on treatment before progression on anti-PD-L1 therapy. This will exclude patients who had rapid progression. Other than this entry criterion for all patients, the trial stratified by PD-L1 status, but did not select for prior IC...
What are your top takeaways in Melanoma from ASCO 2022?
1. Melanoma oral abstract session #3: Abstract 9502 Neoadjuvant PD-1 blockade in patients with resectable desmoplastic melanoma (SWOG 1512)Desmoplastic melanoma is a rare subtype of melanoma that frequently occurs in the head/neck area and is very difficult to completely resect due to its invasivene...