Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In what situations would you place a prophylactic trach prior to radiation for head and neck cancers?
In my practice, the decision on a prophylactic trach is made in a multidisciplinary setting in close coordination with my ENT colleagues. Generally speaking, we will consider placing a trach prior to treatment if there is a high concern for potential airway deterioration during radiotherapy. Clinica...
Should we be giving adjuvant nivolumab to all eligible esophageal/GEJ cancer, irrespective of the PD-L1 status of the tumor?
The FDA approval is regardless of PD-L1 expression. We did not see tumor cell PD-L1 (TPS) enriching for DFS benefit. In a post-hoc exploratory analysis published in the supplementary appendix (S2) of NEJM publication, we evaluated DFS in patients with PD-L1 combined positive score (CPS) >5 compared ...
What factors do you consider to help guide treatment for patients with high grade large cell neuroendocrine cancers of the lung?
High-grade large cell neuroendocrine carcinomas make up a small and aggressive subset of lung cancers that histologically and regarding treatment responsiveness share features with both small and non-small cell carcinomas. These shared features have been borne out in recent sequencing studies of thi...
Is concurrent immuno-radiation therapy a viable treatment option for patients with unresectable, non-metastatic, locally advanced lung cancer, who have high PD-L1 expression and no oncogenic mutations?
Concurrent radiation and immunotherapy would not be recommended for patients with unresectable locally advanced NSCLC.The standard of care in this scenario is concurrent chemotherapy and radiation followed by consolidation durvalumab based on survival improvements seen with the addition of durvaluma...
When treating with SBRT and immunotherapy for unresectable HCC, how do you sequence the treatment?
Great question. No great data in this space regarding optimal sequencing. In general, I would sequence SBRT first, followed by initiation of immunotherapy. Some data suggest that SBRT may best prime IO if administered prior to IO. Additionally, if the IO regimen preferred is atezolizumab/bevacizumab...
Would you offer systemic chemotherapy to a patient with at least 2023 FIGO stage IC high grade serous (p53-mut) endometrial cancer with extensive LVI for whom nodal assessment was not done?
This question was addressed in a large NCDB study in 2020 by Nasioudis et al (Nasioudis et al., PMID 32675056) who looked at USC confined to the endometrium, which found that 5-year OS was 91% for chemo alone, 91% for chemoRT, 85% for those who received radiation alone, and 82% who were observed. Ad...
Do normal methylmalonic acid levels absolutely rule out vitamin B12 deficiency?
An elevated MMA is a good indicator of B-12 deficiency but a normal level does not argue strongly against B-12 deficiency. Normal MMA levels have been reported in 10-25% of patients with known B-12 deficiency (B-12 levels below 100). Testing for an elevated homocysteine level might help but this tes...
If the patient has had prior partial nephrectomy for RCC, would you consider SBRT for a contralateral RCC?
It boils down to the estimated eGFR after SBRT/SABR. Urologists use 15 mL/min as the cut-off. Workup should include a comprehensive metabolic panel and NM renal scan to determine differential renal function. It helps to use a motion dampening technique like abdominal compression or gating to decreas...
Would you offer SBRT to a biopsy proven T1 renal cell carcinoma on a transplanted kidney?
Complex scenario. I am not aware of any cases worldwide of SBRT for RCC in a transplanted kidney. That being said, our group has previously published a case of SBRT for early stage lung cancer in a double lung transplant patient. This was one of 2 known cases at the time, and the details of the case...
Can tamoxifen be safely prescribed for breast cancer patients with cirrhosis?
Tamoxifen would definitely not be my preferred endocrine agent in a patient with cirrhosis. I have had many cases of tamoxifen-induced liver injury. The incidence of MASH due to tamoxifen is really underreported in the literature. In a case of pre-existing MASH or other liver disease, I switch to an...