Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
How does data from the HIMALAYA trial impact your first line treatment selection for advanced HCC?
The results from the HIMALAYA trial with the combination tremelimumab (CTLA-4 inhibitor) and durvalumab (PD-L1 inhibitor) reported an OS of 16.4 months compared to 13.8 months for sorafenib which was statistically significant (HR 0.78, p-value of 0.0035). With the limited data presented at ASCO GI 2...
In patients with advanced endometrial cancer who you plan to treat with chemotherapy + immunotherapy (per GY018 or RUBY), how and when do you utilize adjuvant EBRT and/or brachytherapy?
Reading the question at face value - does advanced endometrial cancer mean stage IVB? III/IVA? If IVB, there is not routinely a role of 'adjuvant' EBRT or BT.Given the discussion of adjuvant therapy, I presume the question is asking for the small fraction of RUBY and GY-018 patients who were stage I...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
Is there a correlation between rectal cancer stage and dose response to radiotherapy?
Possibly. While some compelling data from Appelt et al. in 2013 reflected there may be a correlation between RT dose and rectal tumor response (Appelt et al., PMID 22763027), an extensive number of prospective trials examining the influence of boost doses of RT on pathologic response have produced m...
Are CHEK2 mutations a contraindication for breast conservation therapy with lumpectomy + RT?
Among women with early-stage breast cancer and moderate penetrance breast cancer susceptibility genes, such as CHEK2, decisions about breast surgery are largely based upon personal preferences. According to data from large population-based studies, women with CHEK2 pathogenic variants have about a 2...
How do you approach cisplatin dosing for locally advanced head and neck SCC in HPV-positive and HPV-negative patients?
Weekly cisplatin 40 mg/m² is not yet considered equivalent to high-dose cisplatin 100 mg/m² every three weeks, and high-dose cisplatin remains the preferred regimen for both HPV-positive and HPV-negative locally advanced head and neck squamous cell carcinoma. However, weekly cisplatin is an acceptab...
Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?
Per the trial, this was required within 6 months of starting the study. However, in practice, I don't know that this strict rule would be necessary. For example, what if an EGD was done 10 months ago without varices? I don't think I would feel strongly about this. Similarly, if we could get one shor...
How do you sequence radiation and capecitabine in breast cancer patients receiving adjuvant capecitabine for residual disease after neoadjuvant chemotherapy?
According to personal communication with Dr. Masakazu Toi (June 13, 2017), the corresponding author of the CREATE-X NEJM publication, radiotherapy was administered prior to capecitabine in the majority of cases on this study. It is worth noting that in CALGB 49907, a randomized trial comparing capec...
How do you choose which LHRH agonist or antagonist to prescribe for ADT in patients with prostate cancer?
The choice of LHRH agonist or antagonist depends on patient factors. Most patients receive some form of leuprolide or goserelin since these allow longer intervals between injections (as compared to degarelix). Goserelin is used more for those on anticoagulation or with bleeding disorders since it is...