Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In light of the ROADS data, how are you choosing between intraoperative tile-based radiation therapy (TBRT) and postoperative SRT for newly diagnosed resectable brain metastases?
In light of the ROADS data, I would be cautious about broadly changing practice at this point. While the local control benefit with cesium-131 GammaTile is impressive and biologically plausible, reported OS is much harder to reconcile. A 26% absolute improvement in 2-year OS from a local therapy int...
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?
This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this s...
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...
Is there a period of time after which you would not resume ICI after a patient has had an irAE and required a prolonged steroid taper?
Typically if a patient has required treatment with steroids for four to six months, it was because their irAE was significant (grade 2-4) and refractory to initial treatment. If the patient received combination immunotherapy, such as anti-CTLA-4 and anti-PD-1 agents, one could consider resuming the ...
Would you recommend anticoagulation prophylaxis for a pediatric patient admitted with COVID-19?
COVID-19 disease in children seems to be less severe than adults based on the current literature and our personal experience at Children's Hospitals. Among adults, the coagulopathy is beginning to be described with elevated inflammatory markers and other markers of coagulation activation, including ...
When would you consider Amivantamab + Lazertinib combo for first line in EGFR mutated metastatic NSCLC?
I would certainly consider amivantamab + lazertinib combination treatment in the first-line setting for metastatic EGFR-mutated NSCLC. This is based on the data from the MARIPOSA phase III trial. This trial noted improved survival outcomes in the frontline setting for patients with EGFR exon 19 dele...
In a patient with gastroesophageal adenocarcinoma treated with neoadjuvant chemoimmunotherapy who had a good response but is unable to undergo surgery, how would you approach radiation therapy?
As the ARTDECO study did not show a difference in local control between 50.4 Gy and 61.6 Gy (given with carbo/taxol, but FOLFOX is also an option per PRODIGE5, depending on chemotherapy used as part of the initial chemo-IO), I would suggest 50.4 Gy.
How do you approach choice of second-line therapy in metastatic TNBC after progression on 1L TROP2 ADC?
The emerging consensus on the mechanism of resistance to ADC drugs suggests that payload-mediated resistance predominates over target antigen loss, though both mechanisms operate and their relative contributions differ by disease context. T-DXd-resistant (TDXd-R) and SG-resistant (SG-R) breast cance...
When do you recommend PD-L1 testing for patients with recurrent cervical cancer?
I think getting the testing done as soon as possible is best because very few patients will only need first line therapy. This way, there is less of a delay at the time of progression following/during first-line therapy.