Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In the setting of COVID-19, would you perform a SLNB for a patient incidentally found to have microinvasive ER+ ILC in contralateral prophylactic mastectomy following neoadjuvant chemotherapy for a locally advanced triple positive breast cancer?
I would not recommend SLN biopsy, independent of COVID-19. This patient's prognosis is overwhelmingly dependent on the locally advanced triple negative breast cancer, not the microinvasive ER positive breast cancer. Acknowledging that the ER positive cancer may have been larger than microinvasive be...
In which group of patients you would send for RNAseq for translocations/fusions that might be missed by NGS in advanced NSCLC?
In patients who are never/rare smokers in whom tissue NGS is negative, I would strongly consider RNAseq of a recent or fresh biopsy. You can find the occult fusion (or missed MET) in about 15% of NGS negative, TMB low cases based on this recent very nice paper from MSKCChttps://www.ncbi.nlm.nih.gov/...
Would an intact PTEN but AKT1 mutation still suggest benefit with capivasertib?
Biologically plausible, yes, but not clinically established in prostate cancer. This is an important distinction.Capivasertib inhibits AKT1/2/3, and activating AKT1 alterations can produce pathway dependence. Indeed, outside prostate cancer, capivasertib has demonstrated activity in tumors selected ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Is there any data on the use of PARP inhibitors in patients with metastatic urothelial carcinoma with deleterious DDR mutations?
Urothelial cancers harbor high rate of deleterious DDR alterations. Based on clinical data from other tumor types, especially TOPARP-A in metastatic castration-resistant prostate cancer where responses to olaparib monotherapy were observed especially among men with defective DDR genes, the use of PA...
Is there a role in sending liquid biopsy for patients progressing on ALK inhibitors?
We believe there is increasing value in testing for acquired resistance mechanisms and thereby sending liquid biopsies in patients who progress on ALK inhibitors. The importance was not previously observed as much in patients who progress on first generation crizotinib, since many patients will resp...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
What are the main limitations or barriers to integrating gene expression profiling into routine melanoma management in your practice?
We have no significant barriers to implementing GEP into the management of melanoma in our practice. We do what is best for patients. Any administrative hiccups are easily overcome with a phone call, a fax, or other minimal intervention. When we are dealing with life and death decisions, no effort i...
Would you consider prophylactic anticoagulation for May-Thurner syndrome in pregnancy if prior endovascular intervention has been completed?
In general, I have a very low threshold to initiate prophylactic anticoagulation in pregnancy. For a patient with a history of May-Thurner that has been endovascularly corrected and who has been maintained off of anticoagulation without issue, I would have a risk-benefit discussion about prophylacti...
Can ctDNA be used to evaluate response to checkpoint inhibitors in NSCLC when pseudoprogression is suspected on CT imaging?
This is a scenario where ctDNA may have value in the future, as imaging alone is often not sufficient to reliably differentiate between pseudo-progression and true progression in patients receiving immune checkpoint inhibitors. A small study of 28 patients with melanoma suggested that ctDNA obtained...