Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you decide to transition a patient with stable PNH on eculizumab to extended half-life ravulizumab?
It is not complicated to do the eculizumab->ravulizumab transition. When the next dose of eculizumab is due, I just substitute ravulizumab. The first one is the loading dose and 2 weeks later, the maintenance dose. Following the first maintenance dose, the schedule is every 8 weeks.
How would you approach treatment of DLBCL in a patient on hemodialysis?
For R- CHOP based therapy it can be administered the day before dialysis with no dose adjustments. Only Cyclophosphamide has renal clearance and should be reduced by 50%. For more aggressive regimens it becomes more challenging as there is not enough data. This is what we would consider doing for E...
Do you use trastuzumab for patients with localized HER2+ esophageal cancer after definitive chemoRT who are not surgical candidates?
There is currently no good evidence to support use of trastuzumab as a single agent in esophageal cancer, much less with or following definitive chemoRT. The RTOG 1010 trial will help us to understand the role of trastuzumab in trimodality therapy setting. Based on current evidence, I typically woul...
What is the optimal management of patients with stage II lung cancer without nodal metastasis, but unresectable due to poor pulmonary reserve?
This population of stage II patients without nodal involvement would include T2bN0 (stage IIA) or T3N0 (stage IIB) disease. NCCN 2020 lists either CRT or hypofractionated RT/SBRT as acceptable options. In my experience, if these patients are nonsurgical, then they typically also have multiple co-mor...
Would you offer contralateral prophylactic mastectomy in an older BRCA1 + woman who is getting treated for newly diagnosed BC with mastectomy and SLNB?
Women with deleterious mutations in BRCA1 typically develop triple negative breast cancers. There is a not-insignificant risk of breast cancer in the contralateral breast after a diagnosis of breast cancer. This risk is as high as 20% within 5 years of the primary diagnosis. Even if detected early, ...
Are you de-escalating treatment for favorable risk Stage I-II DLBCL patients to 4 cycles of R- CHOP with 2 additional rituximab cycles?
In general I could see this being an option in select patients (not localized stage II or patients who have a contraindication to XRT) but for the most part these patients in my practice are not treated with 6 cycles of R-CHOP. I treat most patients with Stage I and localized stage II with 3 cycles ...
When, if ever, do you use gemcitabine + erlotinib in patients with metastatic pancreatic cancer?
Never. The benefit in the phase 3 was <10-days without any outstanding responders. Maybe if NGS showed Ras-wildtype and suggested EGFR was a driver.
Is there a role for upfront next generation sequencing in extensive stage small cell lung carcinoma?
The current standard of care is a combination of chemotherapy and immunotherapy (platinum-etoposide with atezolizumab; durvalumab may be an option as well based on the CASPIAN trial). There are no data for targeted therapy, nor is there any evidence to support using any biomarkers to guide immunothe...
Are PD-L1 and molecular markers from pleural fluid specimens reliable enough to guide decision making in metastatic NSCLC?
There is some good data to support the adequacy of malignant pleural effusion specimens as a source of tissue to detect actionable molecular and genetic alterations, if the cellularity of the cell block made from the fluid is adequate (Yang S-R, et al., J Mol Diagn 2018 is one such example). Many la...
Are you testing for PD-L1 IHC expression in extensive stage small cell lung cancer who are planned to be treated with chemotherapy plus immunotherapy?
Based on trial approved chemo-immunotherapy for ES-SCLC, it is not a requirement. IMpower33 (Atezo) and Caspian trial (durva).