Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What do you view as the role for docetaxel+ramucirumab for patients with metastatic NSCLC in light of LUNG-MAP S1800A data?
I still think, at this moment, docetaxel/ramucirumab should be considered standard of care (more below). I would not yet transition to pembro/ram for everyone. A broader issue raised by this trial is whether anti-VEGF drugs, or immunotherapy regimens, alter the efficacy of concurrent or subsequent c...
What factors do you consider when choosing between asciminib vs TKI in a newly diagnosed CML patient?
I think any patient is a good candidate for asciminib, with the exception of those with atypical transcripts (e.g., b2a3, b3a3). The decision would mostly depend on the goals of the patient and the availability and access. Asciminib is particularly well suited for patients who would be interested in...
What factors do you consider when choosing between asciminib vs TKI in a newly diagnosed CML patient?
I think any patient is a good candidate for asciminib, with the exception of those with atypical transcripts (e.g., b2a3, b3a3). The decision would mostly depend on the goals of the patient and the availability and access. Asciminib is particularly well suited for patients who would be interested in...
For patients on commercial teclistamab who achieve a response, are there patient-specific or response-specific parameters that would prompt you to de-escalate therapy from once per week?
I think it’s safe to say we really lack good evidence to guide us. However, we must balance the risk of persistent immunosuppression with teclistamab and its efficacy. The only piece of data I am aware of in this regard comes from ASCO 2023 in an abstract by @Dr. First Last. In the MajesTEC-1 study,...
What adjuvant therapy (regimen and duration) would you use for T2N1 ampullary adenocarcinoma (intestinal type)?
Unfortunately, we don't have randomized data to guide adjuvant chemotherapy for ampullary adenocarcinoma. For the intestinal type, I favor CAPOX or FOLFOX for 6 months. For the pancreatobiliary type, I favor modified FOLFIRINOX for 6 months (PS 0-1) or gemcitabine/capecitabine for 6 months (PS 2).
How do you manage steroid-refractory immune checkpoint inhibitor induced pneumonitis?
Steroid-refractory immune checkpoint inhibitor (ICI)-induced pneumonitis is managed with high-dose steroids plus an additional immunosuppressive agent, like infliximab or intravenous immunoglobulin (IVIG) among others. I recommend early immunomodulatory escalation as multiple studies have shown that...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
What is the risk of local recurrence in a high grade muscle invasive bladder cancer (MIBC) s/p incomplete TURBT treated with concurrent chemoradiation compared to a complete TURBT?
One source I’m aware of that could shed light on this specific question is a 2017 publication from MGH (Giacalone et al., PMID 28081860), reporting the outcomes of 475 patients with T2-4a N0 M0 bladder cancer treated with various protocols from 1986-2013. Not all patients had high-grade tumors, but ...
How would you manage a pre-menopausal woman with extranodal marginal zone lymphoma confined to the bladder wall?
Marginal Zone Lymphoma (MZL) when localized is curable in most instances with modest doses of RT (24-30 Gy), perhaps even less when the primary site is the orbit. It typically responds to rituximab but relapses occur in most cases. Therefore, definitive RT is the treatment of choice in the great maj...
How would you manage a pre-menopausal woman with extranodal marginal zone lymphoma confined to the bladder wall?
Marginal Zone Lymphoma (MZL) when localized is curable in most instances with modest doses of RT (24-30 Gy), perhaps even less when the primary site is the orbit. It typically responds to rituximab but relapses occur in most cases. Therefore, definitive RT is the treatment of choice in the great maj...