Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage LPL with associated AL amyloidosis?
My approach here would depend upon the nature, impact, and severity of the amyloid. Is the LPL IgG or IgM secreting? Is the amyloid causing immediate physiologic harm (renal, cardiac) or asymptomatic radiographic deposits? How much lymphoma and amyloid, respectively? Treatment options include Benda,...
After R1 resection of a locally advanced, node-positive neuroendocrine tumor of the terminal ilium, would you offer adjuvant radiation therapy?
This is a very nuanced question, and I disagree with those suggesting radiation. The great majority of NETs occur at the terminal ileum and the great majority of these tumors are grade 1 or 2. If there was a positive margin it could take many years for that disease to manifest locally. I think radia...
How do you approach adjuvant chemotherapy for high risk/advanced endometrial cancer patients?
For patients with high risk/advanced endometrial cancer where adjuvant therapy is advised, I recommend paclitaxel (175 mg/m2) + carboplatin (AUC 6) (TC) every 3 weeks for 6 cycles. Data from GOG #209 strongly support this recommendation. In this large prospective study, TC demonstrated noninferiorit...
How do you approach hemorrhagic brain metastases in melanoma?
This is a symptomatic brain metastasis from melanoma. Such patients had poor outcomes in the CheckMate 204 trial with dual IO therapy alone. Local control with RT therapy is advised. In our practice, we start with IO-therapy and radiation joins in whenever they are ready with the plan (as GKRS plan ...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
For NSCLC patients treated with neoadjuvant chemoimmunotherapy and surgery with ypN2 disease, what factors would cause you to recommend PORT?
This question is a tough one, and the multidisciplinary teams I work with are still trying to figure it out. This is mostly because only 13% (67/501) of randomized participants in the Lung ART study received neoadjuvant chemotherapy, and 0% received neoadjuvant chemoimmunotherapy; all had pN2 or ypN...
How will you sequence Dato-DXd among available therapies for HR positive, HER2-0 metastatic breast cancer?
While the approval of Dato-DXd for advanced HR+ HER2- breast cancer offers another TROP2 ADC with an improvement in clinical outcomes, there remain several unanswered questions and uncertainty about how to best utilize and sequence the ADCs for metastatic breast cancer. For patients with HR+ HER2 lo...
How does the safety profile of Dato-DXd influence its use in patients with comorbidities or frailty compared to standard chemotherapy?
There were fewer high-grade adverse events seen with Dato-DXd compared to investigator’s choice chemotherapy (20% vs. 45%, respectively), though we do see higher rates of nausea, stomatitis, fatigue, alopecia, and dry eyes or keratitis with Dato-DXd compared to chemotherapy. With the use of prophyla...
Do you recommend adjuvant treatment for nodal isolated tumor cells in an otherwise low-risk endometrial cancer?
Do you recommend adjuvant treatment for nodal isolated tumor cells in endometrial cancer?No, I don’t recommend adjuvant treatment for endometrial cancer patients based on the presence of isolated tumor cells (ITCs) alone, in the absence of other poor prognostic factors. A recent survey on sentinel l...
Will you continue anti-estrogen therapy in the setting of initiation of TDM-1 for patients with metastatic ER+/HER2+ breast cancer?
The answer to this question has not been well studied, but the registration trials that led to the approval of T-DM1 (EMILIA and TH3RESA) did not use T-DM1 with concurrent hormonal therapy. Historically, we have avoided combining chemotherapy with hormonal therapy for breast cancer. This was in part...