Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...
How do you manage a delayed cutaneous reaction to docetaxel after the first cycle of adjuvant TC in early-stage HR-positive, HER2-negative breast cancer?
There is excellent guidance in the literature on management of drug-induced rashes in these patients in Sibaud et al., PMID 27550571. Management generally involves topical and if necessary systemic steroids. I particularly like using lotion versions of topical steroids such as triamcinolone as they ...
Would you consider restarting IMID therapy in a patient with recent stroke while on IMID?
This is a very good question, and practice likely differs across institutions as data is limited. The discussion below refers primarily to the immunomodulatory (IMID) agents lenalidomide and pomalidomide.As you are aware, IMID therapy is known to be associated with an increased risk for venous throm...
When would you offer post-operative concurrent chemoradiation in anaplastic thyroid cancer?
The management of ATC has evolved considerably over recent years with the most significant being a dichotomy of management based on Braf mutation. We typically offer postoperative XRT, including in patients with either a limited or stable DM disease. However, in a multidisciplinary setting, there so...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
How do you approach ADT in patients with high-risk prostate cancer who have risk factors for VTE, such as Factor V Leiden?
My default recommendation for patients with localized, high-risk prostate cancer is to recommend the use of long-term ADT. This intervention seems to offer a relatively large, clinically significant OS benefit for patients in the modern era receiving dose-escalated ADT. This benefit has been observe...
Would you use consolidation immunotherapy after chemoradiation for patients with stage III NSCLC and EGFR amplification?
The short answer is yes, as long as there is no concurrent oncogenic EGFR mutation. During the early days of EGFR-TKI development over 20 years ago, there were different predictive biomarkers proposed and studied. Pitted against each other were biomarkers using more established pathology methods (EG...
In what situations would you treat a rectal mass as cancer despite negative biopsies?
It is not uncommon to see a patient with rectal mass highly suspicious for malignancy by endoscopic evaluation but has a negative biopsy. Usually, this is due to superficial biopsy specimens. In our clinic, we usually get repeated endoscopic evaluation with biopsy as our first step. However, a small...