Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Given potential long-term CV toxicity concerns with lorlatinib and data suggesting that dose reduction does not compromise efficacy, do you ever recommend initiating and/or maintaining lower-dose lorlatinib in ALK+ NSCLC?
It depends. I'm a firm believer in the maximum dose a patient can tolerate and do well on with minimal side effects and maintain a strong quality of life as they live with this for a long time. For an older patient, I would start at 75 mg but for young, I would start at 100 and a low threshold to re...
When should surgical tumor resection be considered in patients with a low-grade glioma?
In adults with low-grade gliomas, there is substantial evidence suggesting that aggressive, early surgical resection improves outcomes and survival (Jakola et al., PMID 23099483). Historically, this has been particularly true for tumors that carry an IDH mutation or 1p/19q codeletion. This survival ...
Do you offer systemic therapy for NSCLC (no driver mutation) after resection of a metachronous solitary brain metastasis occuring after definitive therapy for limited disease, with no evidence of active extracranial disease?
I'm not sure that I have any definitive evidence to present regarding this (ie no trial data), speaking primarily from experience and bias. As I take it, the patient presented in the question is now surgically NED and has had appropriate treatment of his isolated metastatic site of disease with no k...
How do you approach melanoma patients with a positive sentinel node with extra-nodal extension for definitive surgical management?
This is a multidisciplinary question so I reached out to our surgical oncologist (Dr. @Dr. First Last) at the Ohio State University Comprehensive Cancer Center for his thoughts as well. This is a grey area as the patients with extra-nodal extension (ENE) were not specifically studied in the landmark...
How do you do risk stratification for patients with light-chain-only MGUS?
This is a great question, Dr. @Dr. First Last. Apologies for the delay in responding.Light-chain disease is not as clearly defined as heavy-chain disease.There is some guidance here based on current studies, such as Maeng et al., PMID 40295472, revised free light chain reference intervals enhance ri...
What is your preferred treatment option after tarlatamab for patients with ES-SCLC?
The preferred treatment is a clinical trial - and there are several promising agents in development for SCLC, including a number of antibody-drug conjugates targeting B7-H3, Trop2, SEZ6, and DLL3. Outside of a trial, our treatment algorithms focus on chemotherapy, and my preferred agent here is lurb...
What initial systemic therapy would you offer a patient with metastatic colon cancer with BRAF V600E mutation, MSS, who is not an oxaliplatin candidate?
In patients with BRAF-V600E mutant colon cancer who are not candidates for oxaliplatin, replacing the chemo backbone with FOLFIRI is what I’ve done for a few patients without any clinical or insurance issues.This is based on the BREAKWATER study, which, of note, had a FOLFIRI/EC arm - results report...
What second line therapy do you use for metastatic thymoma that recurs following CAP?
Multiple agents can be used to treat recurrent thymoma that requires systemic therapy. Thymoma can be indolent and may not require systemic therapy for some time. Radiation therapy can also postpone the need for systemic treatment in selective cases. Therefore, in some cases, observation is appropri...
Do you take into account ALK fusion variants in your practice for deciding treatment for NSCLC?
EML4-ALK v3 subtypes and TP53 co-mutations tend to be associated with shorter overall survival in patients, and while we take note of these molecular changes, they have not yet been affected by the selection of frontline therapy. I pay attention to ALK mutations, specifically the G1202R mutation, wh...
What time frame, number of PSAs, and calculator do you use for calculating PSA doubling times?
I typically use only values of 0.10 ng/mL or greater, and at least 3 separate PSA values that are at least 3 weeks apart from each other. The greater the number of PSA values, the more accurate the PSADT calculation will be. I like to use the MSKCC calculator: Prostate Cancer Nomograms: PSA Doubling...