Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach for perioperative chemotherapy in MSI-H/dMMR localized gastric cancer?
This question gets at aspects of MSI-H biology, biomarker testing and post-hoc data from the MAGIC and CLASSIC trials suggesting a lack of benefit, and potential negative impact of treatment in MSI-H patients. The following is restricted to gastric cancer, and the rates of MSI-H in true esophageal a...
How do you manage the side effects of ropeginterferon alfa 2b for polycythemia vera patients?
Great question. Although ropeginterferon is better tolerated than other interferons, it is still associated with adverse events. If counts are controlled, I would recommend lowering the dose or spacing out the dosing interval, as that usually helps. For flu-like symptoms, I recommend pre-emptive man...
What would your initial treatment be for an elderly patient with metastatic HER2+ GEJ cancer with PD-L1 <5 who cannot tolerate any platinum agents?
The current standard-of-care is based on the KEYNOTE-811 study, which established the combination of pembrolizumab with trastuzumab and a fluoropyrimidine/platinum doublet for tumors with a PD-L1 CPS of 1 or more. Very recently, trastuzumab has been replaced in the first-line setting by the results ...
How do you manage the side effects of ropeginterferon alfa 2b for polycythemia vera patients?
Great question. Although ropeginterferon is better tolerated than other interferons, it is still associated with adverse events. If counts are controlled, I would recommend lowering the dose or spacing out the dosing interval, as that usually helps. For flu-like symptoms, I recommend pre-emptive man...
Do you perform PDL1 and molecular testing for patients with stages I-III NSCLC?
Do you order PDL1 and molecular testing for patients with stages I-III NSCLC?When I answered this question about two years ago, I said no, primarily because there was no Level 1 efficacy data to support an improvement in outcomes for these patients. This has since changed... although in some ways, n...
For patients with locally advanced GEJ adenocarcinoma with low PDL-1 score, will you still incorporate durvalumab with FLOT therapy?
Yes. I would still incorporate durvalumab with FLOT in patients with locally advanced GEJ adenocarcinoma even when PD-L1 expression is low. MATTERHORN was intentionally designed as an all-comers study without PD-L1 selection, and the event-free survival benefit was observed in the overall population...
For metastatic cholangiocarcinoma that has progressed on first line chemotherapy and immunotherapy, that is HER2 3+, which HER2 regimen is preferred, TDxD, Zanidatamab or tucatinib/trastuzumab?
With the studies specific to cholangiocarcinoma with these agents and risk profile, I’d favor the bispecific Zanidatamab over the antibody drug conjugate T-DXd.Smolenschi et al., PMID 40319675The pneumonitis/ILD is still a black box warning for the ADC and varies between 5-15% depending on which stu...
How should the use of the DecisionDx-Melanoma test be integrated into clinical practice to potentially avoid sentinel lymph node biopsy?
At this time, DecisionDx should be used as an extra piece of molecular information, not for clinical decision-making. The study done on DecisionDx was mainly retrospective, not prospective, so it has limited value in guiding patient care at this time. I would base your decision on SLBx on the curren...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...