Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach early-stage breast cancer patients who are asking for ctDNA or tumor marker surveillance (or previously receiving these with another provider) when these are not part of the NCCN or ASCO guidelines?
In regards to tumor markers, I admit that I follow these in some of my higher-risk (high-risk stage IIB-IIII) patients, despite ASCO and Choosing Wisely guidelines not to do so but am not willing to send these in lower-risk (stage I-IIA) patients, even if they request that I do so, explaining that i...
Do you routinely utilize G-CSF as primary prophylaxis in patients receiving mFOLFIRINOX or FOLFOXIRI?
Interesting to see the differences. I can't speak for others in our large GI practice but as we see well over 1000 pancreas cancer patients/year, there is substantial experience with FFX. I personally do not use primary prophylaxis and I/we do not routinely check DPYD. If neutropenia occurs, we add ...
How would you treat progressive Rosai Dorfman Destombes disease after initial limited radiation therapy?
To provide the best answer, we need a little more detail on this case. Also, is the patient symptomatic from the abdominal disease? If not, I would observe in the short term. If symptomatic, I would do PET/CT and consider a repeat biopsy, given the risk of the development of another process. Do you ...
How would you treat progressive Rosai Dorfman Destombes disease after initial limited radiation therapy?
To provide the best answer, we need a little more detail on this case. Also, is the patient symptomatic from the abdominal disease? If not, I would observe in the short term. If symptomatic, I would do PET/CT and consider a repeat biopsy, given the risk of the development of another process. Do you ...
How do you approach continuing vs discontinuing ovarian suppression for high risk HR+ breast cancer when a patient becomes post-menopausal?
I'm assuming this is a woman in her late 40's or preferably over 50 (I wouldn't trust that a younger woman was permanently postmenopausal no matter what the clinical and lab picture is). It can be challenging to determine that a patient on ovarian function suppression (OFS) is actually post-menopaus...
Is there any benefit of anastrozole in addition to fulvestrant and palbociclib in a patient with HR+ metastatic breast cancer?
We don't have comparative data that I am aware of. SWOG S0226 showed an improvement in PFS/OS for 1st line fulvestrant + anastrozole vs anastrozole, particularly for treatment-naive or > 10-year recurrent metastatic disease. Dr. @Dr. First Last (who led S0226) has opened a phase 2 trial using abemac...
Are there scenarios where you would consider use of capivasertib for non-AKT pathway altered patients given the efficacy seen in the overall treatment population of the CAPItello-291 trial?
While PFS curves are similar in AKT-altered and the overall population, PFS curves are much closer (HR 0.79, 0.61-1.02) in patients with AKT pathway non-altered tumors excluding unknown NGS results (Fig S2), suggesting that the majority of the efficacy is from the AKT-altered population (CAPItello-2...
How would you approach treatment for a R/R mantle cell lymphoma patient with a history of autoimmune hepatitis who has progressed on both a covalent and non-covalent BTKi?
Without the whole story, hard to know if this patient is a candidate for CAR T therapy. Presuming the answer is no, I would give venetoclax. Admittedly this is off label, but venetoclax can be very effective in this disease, both in my personal experience and in the limited available data (Davids et...
How would you treat a BTKi naive p53 mutated MCL in 1st relapse with disease noted both systemically and in the CNS?
This is a case where I would likely still use ibrutinib. We know from years of experience that it gets into the CNS, and it's an incredibly effective drug in MCL. Zanu and acala should get into the CNS, but the companies have limited PK data for CNS penetration. The harder question (I think) is whet...
Following the BRUIN data in mantle cell lymphoma, will you routinely treat with pirtobrutinib following a covalent BTKi?
Yes, this drug has demonstrated clear efficacy in a difficult-to-treat population and perhaps to date, the best safety data with a BTK inhibitor we have seen (low rates of cardiac, bleeding, and GI adverse events). There is a head-to-head study of pirtobrutinib versus covalent BTK inhibitors ongoing...