Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When discussing immunotherapy with patients, how do you frame the conversation in a way that acknowledges the fact that many patients do not respond but allows for hope for a durable response?
There is certainly more than one way to do it. The best way depends on knowing the learning style and information preferences of your patient and then tempering information that they need to have to be informed appropriately. The Shared Decision Making [SDM] model encourages us to invite the patient...
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 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...
Would you recommend adding 4c of adjuvant nivolumab following SBRT to oligorecurrent NSCLC extrapolating from I-SABR results?
Extrapolating I-SABR results to oligo-recurrent NSCLC needs further investigation. Some preliminary prospective randomized studies have indicated that SBRT with concurrent IO may be beneficial for treatment-naive oligo-metastatic NSCLC or oligo-progressive disease after systemic therapy, including I...
Would you recommend 3 or 6 months adjuvant chemo for low risk Stage III sigmoid cancer (T3/N1), but with positive LVI and PNI?
I would recommend 3 months of CAPOX in this case. For a patient with stage III colon cancer, the presence of LVI and PNI should not influence the treatment plan.
For a patient with metastatic colon cancer who tested positive for MSI (i.e. MLH1 hypermethylation etc) and BRAF mutation, what would be your preferred choice in the second line setting?
Approximately 15% of colorectal carcinomas demonstrate mismatch repair deficiency. The majority of these are MLH1/PMS2 deficient due to MLH1 promoter hypermethylation (MLH1ph). BRAF V600E mutations occur in approximately 50% of colorectal carcinomas with MLH1ph. The role of immunotherapy in patients...
Do you offer adjuvant therapy for localized medullary carcinoma of the ascending colon that is MSI-H?
Medullary carcinoma of the colon is a rare type of colon cancer with unique clinical and molecular features. Despite its high-grade histology, its prognosis is generally better than adenocarcinoma. They tend to be locally advanced and rarely metastasize. They are usually MSI-H with a high number of ...
What would you use as adjuvant endocrine therapy for a patient who developed an invasive, hormone receptor positive breast cancer while on raloxifene for almost a decade prior?
In this situation I would use an aromatase inhibitor if possible. One would not expect an ESR1 activating mutation to be readily detected after treatment with a SERM, since estrogen deprivation rather than receptor blockade enriches for ESR1 mutant clones.
After WBRT, what systemic therapy would you favor for maximal CNS penetrance in a patient with triple negative metastatic breast cancer and multifocal CNS disease?
With patients such as this, I would usually recommend the following: 1. Genomic testing (Strata, Foundation 1, etc.) to look for a mutation that might be targetable with a TKI that crosses the blood brain barrier well 2. Re-testing of the CNS cytology for HER2, given that we do have multiple drugs w...
How do you choose first or second-line systemic therapy for fibrolamellar hepatocellular carcinoma?
Fibrolamellar carcinoma is histologically unique from hepatocellular carcinoma. The disease is correctly called fibrolamellar carcinoma, and not fibrolamellar hepatocellular carcinoma, or hepatocellular carcinoma fibrolamellar variant. Even though the latter may be permissive if the lack of cirrhosi...