Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with NSCLC on osimertinib who progress, would you continue osimertinib when moving onto chemotherapy for 2nd line therapy?
It all depends if we have systemic vs non systemic acquired resistance. You can continue osimertinib if you have slow progression or oligomets can be treated with local therapy like radiation. Sometimes you can increase the dose to 160mg if only CNS progression and asymptomatic. In case of systemic ...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
How do you approach work-up for a patient suspected for monoclonal gammopathy of renal significance for whom renal biopsy is contraindicated?
Not very many reasons that a renal biopsy could not be done, but I would consider doing a bone marrow biopsy if the free light chain ratio was significantly abnormal, i.e. a ratio of 3 or greater. A reminder that in renal failure, both light chains may be elevated, but the ratio in benign processes ...
Would you consider antiphospholipid syndrome to be a contraindication for checkpoint inhibitor immunotherapy?
Checkpoint inhibitor therapy is usually an important treatment for patients with advanced malignancy, and has greatly improved the prognosis of otherwise untreatable cancers, so I would not automatically proscribe these drugs because of a history of APS. I would ensure patients with APS are on full ...
How would you treat a patient with recurrent DLBCL 15 years after definitive treatment of initial de novo disease with R-CHOP?
As a new primary DLBCL, but with previous exposure to 6 cycles of doxorubicin, I would only give RCHOP x 2, then RCEOP x 4. If interim PET showed a poor response, I would switch to a CAR T-cell therapy as 2L therapy.
Based on the results of SWOG S1801, neoadjuvant vs adjuvant pembrolizumab for resected stage IIIB-IV melanoma, are you starting to recommend neoadjuvant pembro for your patients?
Yes, I now usually would recommend neoadjuvant therapy for melanoma stage 3. If a clinical trial is open, I prefer to enroll patients in it. Patients who have contraindications to immunotherapy are treated with surgery first.
What adjuvant therapy would you offer following adjuvant chemotherapy for a patient with Stage III lung adenocarcinoma with an atypical EGFR mutation such as EGFR L861R?
Mutations at position 861 (most commonly L861Q) have been described, occurring in approximately 2% of all EGFR-mutant patients [Mitsudomi and Yatabe, PMID 19922469]. These mutations are considered partially sensitizing to afatinib based on a post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung ...
Would you offer local therapy to a patient with GEJ adenocarcinoma with FDG-avid para-aortic node oligometastasis?
I have favored induction systemic therapy and interval re-assessment. If responsive or at least stable disease, I have offered extended field CRT as long as the treatment volume seems reasonable and my perception is that it would be tolerable when assessed in the context of a patient’s performance s...
Do you offer anticoagulation to patients with prior antiphospholipid antibodies detected in pregnancy without a history of pregnancy loss or thrombosis?
I do not know what the risk of pregnancy loss is in a woman without a prior history of VTE or pregnancy loss. I am sure the risk is affected by whether the woman has an underlying rheumatological disease (SLE) and whether she has single positive vs. triple positive LAC. I recommend a baby aspirin on...
For a rectal cancer with questionable T3 or questionable N+ by MRI, can short course radiation be given followed by surgery and the pathology still be interpreted to guide adjuvant chemotherapy?
This is a somewhat common scenario. In these situations, I have strongly favored short course RT followed by immediate surgery such that there is not a sufficient time interval between RT and surgery to allow any significant pathologic response. I think you can be confident in that the pathology aft...