Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How are you approaching patient selection and timing of RNA-based NGS, in light of the approval of zenocutuzumab for NRG1 fusion–positive advanced cholangiocarcinoma?
My standard has been to do all DNA, RNA, and IHC through a single vendor. I test all newly diagnosed patients with cholangiocarcinoma. I always do tissue and liquid biopsy NGS. If tissue biopsy is not feasible because of sample quantity/quality, then another biopsy will be the way to go to obtain, e...
Do you offer consolidation durvalumab in a patient who had pneumonitis requiring steroids following chemoradiation for LS-SCLC?
In the ADRIATIC trial, pneumonitis or radiation pneumonitis occurred in 38.2% of durvalumab-treated patients, and 8.8% discontinued treatment due to pneumonitis (Cheng et al., PMID 39268857). While there is emerging interest in immune checkpoint inhibitor rechallenge after successful management of i...
Are you altering your use of immune checkpoint inhibitors given the risk of immune-related pneumonitis and the COVID-19 outbreak?
The management of advanced cancer patients has gotten even more complex with the COVID-19 pandemic. In general, providers are trying to keep patients away from the hospital/clinic as much as possible, and avoiding regimens with greater toxicity if there are suitable less toxic alternatives. Whether ...
For patients with EGFR mutation positive NSCLC who progress on first line TKI without actionable resistance mechanisms, would you consider chemotherapy + targeted therapy as a second line option, or chemotherapy +/- immunotherapy?
Although the question assumes no actionable changes in the lung cancer, I do refer you to an excellent review of this topic, published last September (Piper-Vallillo et al., PMID 32552277), which included a table listing twenty-five open clinical trials for patients who have developed progression af...
Should we be stopping new starts of patients who can be triaged for 2-3 months like prostate cancers on ADT when significant community spread of COVID-19 is detectable in our area?
I would for those patients requiring ADT, which is the way I interpreted the question. I want to elaborate more because @Dr. First Last brought up other scenarios we should consider and he brings some more good points: Many patients could get active surveillance for a period of time before ADT is co...
Do you offer either zoledronic acid or denosumab for patients with mCSPC with lytic metastases at baseline due to intraductal histology or high grade pathology?
This is an interesting question that we do not directly have evidence for. I usually do not offer patients bone protective therapy in this setting. Bone-protective therapy, in my opinion, is beneficial in preventing fractures, really for two reasons: Pathologic fractures. mAPMS disease (formerly mC...
How do you utilize lenalidomide maintenance in non-transplant eligible myeloma?
Maintenance is a standard of care management for both transplant eligible and transplant ineligible, regardless of type of induction regimen. Studies have shown benefit for both groups. Time to progression (PFS) almost twice as long for both groups with maintenance compared to no maintenance. - For ...
How do you utilize lenalidomide maintenance in non-transplant eligible myeloma?
Maintenance is a standard of care management for both transplant eligible and transplant ineligible, regardless of type of induction regimen. Studies have shown benefit for both groups. Time to progression (PFS) almost twice as long for both groups with maintenance compared to no maintenance. - For ...