Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is it appropriate to dose de-escalate in low risk HPV+ SCC of the oropharynx outside of a clinical trial setting?
I am going to write specifically on de-escalating HPV-OPSCC in the adjuvant setting first, important caveats for adjuvant de-escalation, and then about the general philosophy on de-escalation in clinical trials.Concerning adjuvant treatment, after careful consent, we are de-escalating patients with ...
Do you ever change treatment for metastatic breast cancer with rising tumor markers, but no evidence of progression on imaging?
I do not change treatment based on just tumor markers in advanced breast cancer. When there is significant rise in the level of tumor markers, one should be following the patient closely since this could be an indication of disease progression about to declare itself. There are no well conducted lar...
How would you approach a patient with pancreatic adenocarcinoma who completed 6 months of adjuvant chemotherapy without evidence of disease on imaging but an elevated CA 19-9?
In patients with an elevated CA 19-9 and no obvious evidence of visible disease on routine cross-sectional imaging, a thorough evaluation should first be done to exclude occult metastases. This may include bone scan and/or brain MRI, as indicated. If after a complete evaluation, no visible disease i...
Would you consider omission of PORT for node+ NSCLC with a positive margin in the setting of a high tumor PD-L1 score and plans for immunotherapy?
For gross positive margins (R2), no, adjuvant chemoRT followed by consolidation immunotherapy. For R1, SOC would still say PORT and adjuvant systemic therapy. But let's try to tease it out in a more nuanced way from available data. First PD-L1 high is certainly a check in the plus column for a clini...
What is your approach to adjuvant endocrine therapy in high-risk premenopausal women with ER/PR+ Her2+ breast cancer?
There are no large scale modern era assessing the role of adjuvant hormonal therapy in patients with HER2+ and hormone receptor positive breast cancer. Data from metastatic trials and cohort studies do suggest that there is an interaction with concurrent hormonal and HER2-targeted therapy and the tw...
How do you decide between RPLND vs. chemotherapy in patients with Stage IIA mixed germ cell tumor as primary treatment?
I agree but would add a few comments: If there is a rising hCG or AFP above normal values, we prefer BEP X 3 rather than RPLND. If the patient > age 50, EP X 4. Also, we consider any AFP < 25 to be “ normal” despite many labs listing 0-8 as their normal range. Our group recently published data in J...
What is the optimal approach to managing oral toxicities, such as dysgeusia, caused by immune checkpoint inhibitors (ICIs)?
Unfortunately, this is a very strange side effect of ICI. I have seen this a few times in my clinic, and mechanistically, in my humble opinion, this is a neurologic irAE. I also notice patients losing tremendous amounts of weight due to the inability to taste and eat food. There is no good fix for t...
How do you monitor and manage minimal residual disease (MRD) in patients with core-binding factor (CBF) AML who are in remission post-induction and consolidation therapy?
For the purposes of this question, we will presume this refers to patients who are MRD-negative by a PCR-based methodology and have completed induction chemotherapy and consolidation.Puckrin et al., PMID 31896684 reported on 114 patients with CBF-AML who were treated with intensive chemotherapy and ...
How do you monitor and manage minimal residual disease (MRD) in patients with core-binding factor (CBF) AML who are in remission post-induction and consolidation therapy?
For the purposes of this question, we will presume this refers to patients who are MRD-negative by a PCR-based methodology and have completed induction chemotherapy and consolidation.Puckrin et al., PMID 31896684 reported on 114 patients with CBF-AML who were treated with intensive chemotherapy and ...
How would you treat a patient with newly diagnosed ALK+ Stage IIIB non-small cell lung cancer (NSCLC)?
Stage IIIB encompasses T3-4N2 and T1-2N3, so I will assume that we are not going to consider a neo-adjuvant approach. Standard treatment for stage IIIB ALK+ NSCLC would be definitive concurrent chemo/RT given with curative intent. Reasonable chemo regimens would be weekly carboplatin plus paclitaxel...