Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Does the presence of a KEAP1 mutation influence your decision to use adjuvant immunotherapy in stage II–III melanoma?
It is an interesting thought when you look at the mutations that may predict resistance to checkpoint inhibitors. However, I do not think we are at a stage where we can make a firm decision in the adjuvant setting (or any other setting) based on mutation profile. If there is a concomitant BRAF mutat...
How do you prioritize treatment in a lung cancer patient who has HER2 IHC3+ along with other actionable mutations that have tumor-specific drugs available?
Non-small cell lung cancer (NSCLC) can harbor different HER2 alterations: HER2 protein overexpression (2-35%), HER2 gene amplification (2-20%), and HER2 gene mutations (1-4%). Unlike breast or gastric cancer, HER2 protein overexpression in NSCLC is not a validated biomarker for first-line HER2-targe...
In a patient with de novo stage IV breast carcinoma harboring an RB1 Q395* (nonsense) mutation, would treatment with a CDK4/6 inhibitor be appropriate, or should it be avoided due to likely resistance?
HR+/HER2- with baseline RB1Q395* nonsense mutation. This is one of those incredibly tough, "data-free zone" scenarios where standard guidelines fail us, and we have to rely heavily on clinical judgment and the underlying biology. In a de novo metastatic setting, our reflex is always to reach for a C...
Assuming regulatory approval, what role do you foresee for varegacestat (RINGSIDE) in the management of progressive desmoid tumors, particularly in relation to existing systemic treatment options?
Once-daily dosing is certainly more attractive from the patient's perspective. Apart from that, I do not foresee many differences in the impact on how we manage desmoid tumors. Since this was also a placebo-controlled trial, there is no way to judge it against nirogacestat.
How do you decide on treatment modality for ocular surface squamous neoplasia?
For primary OSSN, my initial treatment modality will either be wide surgical excision with cryotherapy and amniotic membrane graft or medical treatment with 5-Fluorouracil drops QID x7 days, followed by a 3-week drop holiday. I find that there is little to no downside to trying 5-FU first, given tha...
How do you approach patients with stage III unresectable, combined histology NSCLC/SCLC?
For stage III lung cancer with mixed NSCLC and small-cell lung cancer, we treat patients with concurrent chemotherapy (cisplatin/etoposide every three weeks) and definitive radiotherapy (60-66 Gy in 30 fractions, QD), followed by adjuvant immunotherapy (durvalumab). The rationales are as follows: Ra...
Which early-stage breast cancer patients who are candidates for 3-week hypofractionated whole breast EBRT are not good candidates for 1-week whole breast EBRT?
One important dosimetric criteria for 5.2 x 6 is V105 of 5% or less and v 107 of 2% or less. For 3-week RT, our data suggest v105 < 10% caused less morbidity. These dose homogeneity constraints are sometimes hard to meet for moderate or large size breasts, and one needs to be careful. Also, if a bo...
How do you decide when to pursue malignancy workup for patients with cryptogenic stroke?
Agree with above. I would also pursue malignancy work-up in this scenario as well: currently on anticoagulation (whether for afib or another medical reason) and has an ischemic stroke on top of that.
How do you decide when to pursue malignancy workup for patients with cryptogenic stroke?
Agree with above. I would also pursue malignancy work-up in this scenario as well: currently on anticoagulation (whether for afib or another medical reason) and has an ischemic stroke on top of that.
How do you approach treatment of a young adult with an intracranial anaplastic ependymoma and a single intradural cervical spine metastasis?
A high-grade tumor, such as anaplastic ependymoma, carries a higher risk of CSF seeding down the neuroaxis than lower grades. Secondary spinal drop metastases are considered a serious but relatively rare complication in this disease. Assuming that the metastasis was detected at the time of diagnosi...