Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What high-risk features for stage I NSCLC would lead you to consider adjuvant osimertinib?
In patients with resected stage IB non-small cell lung cancer (NSCLC) harboring EGFR mutations, adjuvant osimertinib may be considered for care. There is some evolving data that there may be some benefit in the presence of other risk factors in stage I, including solid or micropapillary histologic c...
Given the updated results of the PREOPANC study, how can gemcitabine-based neoadjuvant chemoradiation be best incorporated into the treatment of resectable or borderline resectable pancreatic cancer?
The PREOPANC-1 trial and the study by Jang et al., PMID 29462005 are currently the only 2 published randomized trials comparing pre-op CRT vs up-front surgery for resectable/borderline resectable PDAC- each of which has now demonstrated an overall survival benefit. The obvious critique is the standa...
How do you choose between the different available CAR-T cell therapy products for the treatment of relapsed Ph-negative ALL?
As implied by the question, there are now three (3) CD19 CAR-T cell products approved by the FDA for adults with relapsed/refractory B-ALL: tisagenlecleucel (tisa-cel), brexucabtagene autoleucel (brexu-cel), and obecabtagene autoleucel (obe-cel). They were all approved after single-arm prospective t...
When will you select Dato-DXd for patients with EGFR-mutated non-small cell lung cancer?
I would select Dato-DXD for patients with EGFR-mutated NSCLC, after I have trialed osimertinib and amivantamab in the first- and second-line setting. I usually include chemotherapy with one of these two medications as well. If a patient fails both of these treatments, I would consider Dato-DXD at th...
Do you hold maintenance lenalidomide or bortezomib for a patient who needs a surgery?
I'm not aware of any formal data to guide this recommendation. In general, I do not recommend holding maintenance lenalidomide or bortezomib for surgery. I do hold maintenance for treatment if/when: - the patient has cytopenias from treatment and would benefit from improved counts from a treatment b...
Do you hold maintenance lenalidomide or bortezomib for a patient who needs a surgery?
I'm not aware of any formal data to guide this recommendation. In general, I do not recommend holding maintenance lenalidomide or bortezomib for surgery. I do hold maintenance for treatment if/when: - the patient has cytopenias from treatment and would benefit from improved counts from a treatment b...
Do you consider FOLFIRINOX dose adjustments for elderly patients with a good performance status in the neoadjuvant setting for resectable pancreatic adenocarcinoma?
This is a question worth revisiting in light of recent data. The question assumes that we would prefer to use FOFLIRINOX as peri-operative treatment in resectable PDA and this is commonly the case based on extrapolation from cross-trial comparisons of randomized data evaluating combination therapy i...
In cases where EGFR NSCLC has transformed into small-cell lung cancer after treatment with osimertinib, and with no CNS involvement, is it advisable to continue osimertinib alongside chemotherapy?
There is a paucity of data to guide treatment decisions in this context. Transformed small cell lung cancer is a complex phenomenon wherein some oncogene-driven lung cancer clones undergo a series of transcriptomic and epigenetic changes (such as EMT-like changes and methylation-driven events) as a ...
What is the appropriate monitoring for an incidental low-grade rectal neuroendocrine tumor resected endoscopically with positive margins?
Do we have information on the size of the lesion? Typically, if it was a positive biopsy and the size of the polyp was <1 cm, we typically rescope and biopsy the scar. It can harbor residual disease (40% incidence), which a deeper resection can cure. And then these patients don't need surveillance. ...
What pathologic response criteria do you use to determine the need for further adjuvant therapy in patients with breast cancer?
The question about which response criteria might guide further adjuvant therapy in HR+ disease after neo-adjuvant chemo is of unclear clinical significance currently. Until CDK4/6 inhibitors receive an FDA indication in the adjuvant setting, the only "systemic therapy" decision to be made after neo-...