Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What would you offer a patient with MSI-high metastatic endometrial cancer after disease progression on pembrolizumab?
It appears that it has been two years since the last platinum therapy (progressed after 1 year, then on immunotherapy for one year) so it's very reasonable to consider the use of platinum-based chemotherapy again, an option could include platinum + taxane + bevacizumab to add a targeted therapy to t...
For patients with KRAS G12C mutated NSCLC, how would you decide between using targeted therapy with sotorasib vs adagrasib?
Sotorasib is currently my drug of choice for now, since it is FDA approved. The KRYSTAL-1 results for adagrasib were presented at ASCO 2022, and the efficacy is very similar vs sotorasib, 43% vs 37% ORR, 80% DCR for both, 6.5 vs 6.8 mo mPFS, and 12.6 vs 12.5 mo mOS. Adagrasib does seem to have more ...
How would you approach evaluation and treatment of a patient on pembrolizumab therapy who presents with symmetric, proximal, upper extremity and lower extremity painful weakness without an elevated CK?
Pembrolizumab, like other checkpoint inhibitors, is associated with a number of immune mediated neuromuscular syndromes including GBS/CIDP, a myasthenic syndrome, and myositis. A patient with symmetric proximal weakness and normal CK could have any of the above conditions. Normal CK does not exclude...
What are best practices for medical oncology clinics during the COVID-19 pandemic?
Agree with @Dr. First Last's response. Here are some of our guidances (with the caveats that there are exceptions to all of these, and they are dependent on clinician-patient discussions): Patients with active COVID-19 infection Delay/stop oncologic therapy (chemotherapy, radiation, surgery) until ...
Of the two ipilimumab dosing schedules utilized with nivolumab on CheckMate 8HW, do you have a preference in your own practice?
As ipilimumab often drives the increased toxicity of dual checkpoint inhibitors in comparison to monotherapy, multiple dosing regimens have been used across tumor types. Patients tend to do better with either short courses of ipilimumab (such as the Q3 week dosing for 4 cycles) or longer periods bet...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
How would you treat suspected secondary HLH in patients whom etoposide is contraindicated?
Thank you for the interesting question. It would be helpful to understand why etoposide is contraindicated. My general approach for these patients is to first ensure that there is no evidence of malignancy as a trigger as you do not want to mask that with steroids (I strongly recommend obtaining a P...
How would you manage a recurrent cervical cancer previously treated with vaginal cuff brachytherapy and has had a complete response to chemo-immunotherapy?
Ling et al., PMID 30600093 -The paper gives our philosophy in this scenario. The total dose is the function of dose to target and cumulative dose to rectum and bladder. To be able to give a higher dose with brachy, generally would favor around 30.6 Gy with EBRT and then limit the last 14.4 Gy to the...
How would you treat a p16+ squamous cell carcinoma confined in the recto-vaginal septum with no suspicious adenopathy on PET or MRI?
Early vaginal or anal cancer still has relatively high rates of lymph node involvement. In vaginal cancer, T1 lesions have lymph node involvement rates of 5 - 15%. In anal cancer, T1 lesions have a higher rate of 5 - 50%. If there are no mucosal changes then it is possible this is an in-transit LN f...
Will you give perioperative chemotherapy with EGFR inhibitors for stage IV left-sided RAS/BRAF WT colorectal cancer with resectable/borderline resectable liver metastases given discordant PARADIGM vs New EPOC trial results?
This is a very controversial topic/discussion.The New EPOC study was a multicenter, open label, randomized phase 3 study that enrolled 257 patients with KRAS wild-type resectable or suboptimally resectable colorectal liver metastatic disease. Patients were randomized to systemic chemotherapy with or...