Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you choose first or second-line systemic therapy for fibrolamellar hepatocellular carcinoma?
Fibrolamellar carcinoma is histologically unique from hepatocellular carcinoma. The disease is correctly called fibrolamellar carcinoma, and not fibrolamellar hepatocellular carcinoma, or hepatocellular carcinoma fibrolamellar variant. Even though the latter may be permissive if the lack of cirrhosi...
What is your preferred first line treatment option for a fit patient with non-squamous NSCLC who is PDL1 positive (1-49%) with no driver mutations?
My preferred first line option for patients with advanced NSCLC and PDL1 TPS score of >1% and <50-% remains chemotherapy with immunotherapy. I prefer carboplatin- pemetrexed -pembrolizumab for nonsquamous and carboplatin-taxane-pembrolizumab for squamous cell NSCLC. I might consider Nivolumab Ipilim...
For a patient s/p laryngectomy with positive margins, would you start radiotherapy 6 weeks s/p surgery if there is a delay in concurrent chemotherapy?
The question is a bit challenging without understanding the reason why the patient is suited for XRT but not chemo. My best guesses would be a concurrent infection or PS issues, possibly due to deconditioning after a hard surgery.However, part of the decision would involve when it is anticipated tha...
How do you conduct follow-up on patients with brain mets who have undergone GammaTile placement?
For patients with high-grade gliomas, they get an immediate post-implant CT and MRI for dose calculation, then I schedule serial follow up CE-MRI every 9-10 weeks for at least a year; if stable at the one-year mark, I "graduate" the patient to get MRIs every 12 weeks for the second year of follow-up...
In light of promising results of hydroxychloroquine in COVID-19, should we consider using it prophylactically in cancer patients, especially if immunocompromised?
At this time, as there is no good evidence available, I would not recommend the use of hydroxycholoroquine prophylactically in cancer patients. It is unclear whether it would prevent contagion, probably not, and we still don't know if it will have any effect on the course of COVID-19. We expect ther...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
Would you hold immunotherapy if a patient with metastatic melanoma has stable disease for 6 months?
We would usually not stop therapy in a patient with a stable disease as best response after only 6 months. In Keynote 006, patients had to stop therapy after 2 years of treatment. In this trial, 12 patients were in stable disease after 2 years. Ten of them were still in stable disease after 9 months...
For which non-BRCA pathogenic germline variants, if any, might you consider recommending chemoprevention with SERM/AI?
The breast cancer prevention trials enrolled women with a risk of developing breast cancer equivalent to a 60-year old woman with no other risk factors. That is not a HIGH risk. Chemoprevention has been dramatically underused in both the truly high risk (if pathogenic mutation carriers) as well as t...
For patients with locally advanced rectal cancer who desire organ preservation and can tolerate fluoropyrimidine but not oxaliplatin, what is the appropriate treatment approach?
For patients with locally advanced rectal cancer who desire organ preservation and cannot tolerate oxaliplatin, the appropriate treatment approach would be neoadjuvant, long-course radiotherapy combined with fluoropyrimidine-based chemotherapy. After neoadjuvant treatment, patients are ev...