Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your surveillance approach for outpatient monitoring of ICI myocarditis?
Screening and surveillance strategies for outpatient monitoring of ICI myocarditis are not well-defined. The best surveillance approach would be based on clinical risk assessment, followed by biomarker and imaging data. The risk factors for ICI myocarditis remain to be clarified, but the most valida...
For patients with large, partially or nearly obstructing rectal cancers, how do you sequence TNT in order to avoid complete obstruction and surgical diversion?
I personally favor starting with RT/chemo, but starting with chemo can work well. The more important issue is the side questions. First, there is a huge difference between a lesion that is large and one that is nearly completely obstructing. Unfortunately, many endoscopists use the term "obstructing...
Would you consider proton therapy as part of TNT for rectal cancer?
Show me the data. Our results with conventional 3D XRT are excellent with a low rate of chronic toxicities and even lower rates of pelvic recurrences.
Would you offer inguinal nodal RT to a patient with anal SCC (pT1N1a, + inguinal node) following APR in the setting of prior prostate + pelvic nodal radiation?
Inguinal lymph node dissection is not typically part of APR procedures. Even when surgical dissection of the inguinal lymph nodes is performed, the recurrence or failure rates in this region can still be significant, with some studies reporting failure rates of around 10-15% despite extensive surger...
Do you still offer adjuvant chemotherapy and chemoradiation for NSCLC after neoadjuvant chemoimmunotherapy?
In the pre-neoadjuvant era, the options for patients who had R1 (positive margin) or R2 (gross residual disease) were: re-resection followed by adjuvant chemo; sequential adjuvant chemo followed by radiation; or concurrent chemoradiation. There is retrospective data suggesting a survival benefit fro...
How do you treat MAS in patients with systemic JIA or AOSD with HLA-DRB1*15 alleles given risk for DRESS hypersensitivity to IL1 or IL6 inhibitor therapy?
Tough question. HLA-DRB1*15 is pretty common, and it may be a risk allele for lung disease. I, and many others, are not convinced, however, the lung disease represents DRESS, nor that a range of biologics are the etiology of the lung disease. One of my most recent sJIA patients presented with high e...
For a patient with a metastatic solid tumor in remission on a checkpoint inhibitor who also has R/R multiple myeloma, would you feel comfortable with a bispecific T-cell engager antibody?
The short history of checkpoint inhibitors in myeloma has raised some issues with their use. Of course, in this scenario, they are being employed for other cancers, but they may be instructive nonetheless, especially as it pertains to combination strategies. IMiDs and checkpoint inhibitors don't se...
Is post-mastectomy chest wall radiotherapy indicated for DCIS with very close (<1 mm) or positive margins?
As with most clinical situations with limited data, individualized decision-making is key. Based on small series, I do not generally offer RT post mastectomy for DCIS if it is close. If it is clearly involved after reviewing with the pathologist, I would discuss with the surgeon and patient taking i...
Do you recommend CDK4/6 inhibitor, radiotherapy, or both following surgery for a pathologic fracture from HR+ breast cancer?
The goal of therapy is to help control pain and enhance healing. Post-op RT is routine with the most common dose used by us being 20 Gy in 5. It’s reasonable to do with concurrent CDK4/6 inhibitor.https://www.ncbi.nlm.nih.gov/pubmed/31360799
Would you consider using sotorasib first line in patient with metastatic KRAS G12C NSCLC who declines chemotherapy?
This would be outside the scope of available data and current FDA approval. Both CodeBreaK100 and CodeBreaK 200 (presented at ESMO) included only patients previously treated with either chemotherapy, immunotherapy, or both. I would generally stick to standard first line options for these patients, e...