Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you prioritize TACE or systemic therapy in BCLC B multifocal HCC with tumor bulk higher than "up to 7?"
This is a challenging area where we need more definitive studies. With the info available, I do favor systemic therapy for such patients. Liver directed therapy is unlikely to lead to adequate control for such multifocal disease and the patient is likely to require multiple treatments to different a...
Would the need for infliximab/MTX/nonsteroidals to control initial irAE affect your decision to rechallenge these patients with ICI?
Infliximab and methotrexate are generally used in irAE grades 3 or 4, or in grade 2 irAEs that are refractory to initial treatment with steroids. Methotrexate is typically used for irAEs of the musculoskeletal system, such as inflammatory arthritis or myositis. Infliximab tends to be used in the set...
How does data from the HIMALAYA trial impact your first line treatment selection for advanced HCC?
The results from the HIMALAYA trial with the combination tremelimumab (CTLA-4 inhibitor) and durvalumab (PD-L1 inhibitor) reported an OS of 16.4 months compared to 13.8 months for sorafenib which was statistically significant (HR 0.78, p-value of 0.0035). With the limited data presented at ASCO GI 2...
Is there a role in sending liquid biopsy for patients progressing on ALK inhibitors?
We believe there is increasing value in testing for acquired resistance mechanisms and thereby sending liquid biopsies in patients who progress on ALK inhibitors. The importance was not previously observed as much in patients who progress on first generation crizotinib, since many patients will resp...
Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?
Though some clinicians have been exploring the idea of targeted therapy for EGFR mutant brain metastases, this has been done in the absence of strong evidence. Reasons for pushing this idea are that sometimes the lesions seem to respond, and this has been seen in some single arm studies and anecdota...
When should you use single-fraction radiotherapy for spinal cord compression?
The SCORAD III trial is practice changing. But I do NOT plan to treat ALL patients with spinal cord compression with a single fraction of 8 Gy now. Here is why: SCORAD III is extremely important new study for the management of metastatic epidural spinal cord compression (MESCC) for patients with sho...
Do you perform PDL1 and molecular testing for patients with stages I-III NSCLC?
Do you order PDL1 and molecular testing for patients with stages I-III NSCLC?When I answered this question about two years ago, I said no, primarily because there was no Level 1 efficacy data to support an improvement in outcomes for these patients. This has since changed... although in some ways, n...
How do you approach a stage IIIC triple positive IDC, s/p neoadjuvant TCH and P, lumpectomy, and ALND with significant residual disease at the time of surgery?
I would use adjuvant T-DM1 for residual disease after standard neoadjuvant therapy for HER2+ breast cancer as described in this case. We have strong evidence from the KATHERINE randomized trial that adjuvant T-DM1 compared to trastuzumab that cuts recurrence risk by about 50% in this situation. Whil...
How do you counsel patients on the efficacy of breast cancer risk reduction strategies such as breast MRI surveillance or bilateral mastectomy for those considered high risk by polygenic risk score, pathogenic variants, and/or family history?
This is a difficult question with limited data to guide decisions. The ultimate goal of any screening effort is to identify disease earlier so that treatment is more effective (and hopefully less onerous) so that fewer patients die. We have good data that enhanced screening in high risk populations,...
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
In the case of a patient with untreated chronic hepatitis C, I would offer upfront atezo/bev, as long as hepatic function is appropriate. At our center, hepatitis C treatment is generally not offered to patients with advanced HCC. Interestingly, only 21% of patients treated with atezolizumab/bevaciz...