Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with HER2+ breast cancer treated with T-DXd in neoadjuvantly who has residual disease on surgical pathology, what will be your adjuvant therapy approach and why?
In the DESTINY-Breast11 trial, patients with > T3, or N+ or inflammatory breast (although the FDA approval included T2N0) who had residual disease got the standard of care at the time, which was T-DM1 x 14 cycles. However, recently adjuvant T-DXd was approved based on the DESTINY-Breast05 data for p...
How do the results of the phase 2 TREASURE trial for consolidative RT for ES-SCLC impact your practice?
Thoracic radiotherapy is defined not only by dose, but critically by treatment volume. The TREASURE protocol permitted large CTV expansions, discretionary irradiation of clinically uninvolved nodal regions, and substantial additional PTV margins. Elective nodal irradiation is not part of contemporar...
Would you use bevacizumab in a patient with advanced HCC and multiple large esophageal varices that have not been endosopically intervened upon?
Large varices should be treated endoscopically. I would avoid using Atezo/bev in a patient who has not had adequate treatment of their varices as there is a real risk of bleeding with bev in this setting.
What is your platelet cutoff for atezolizumab + bevacizumab in HCC in the absence of bleeding (variceal or otherwise)?
The platelet eligibility for IMBrave150 was 75K, I believe. Eligibility in the original SHARP trial was 60K, so I often consider somewhere around 60K. Although if truly no varices on EGD and no history of bleeding, I might consider down to 50K. Lower than that, I would probably think single agent ch...
Do you routinely check EGFR mutational status in all resected NSCLC regardless of histology?
In the ADAURA trial, non-adenocarcinoma histology comprised < 5% of cases, which reflects the well-known distribution of sensitizing EGFR mutations which is largely found in adenocarcinomas. However, for patients who are never smokers or have remote light history of smoking with different NSCLC hist...
How will the ADAURA study impact your use of adjuvant chemotherapy?
ADAURA has not and will not impact my use of adjuvant chemotherapy. Many prospective studies have demonstrated a clear significant improvement in overall survival with the use of adjuvant chemotherapy after complete surgical resection. This is standard of care for the appropriate patients. Osimertin...
Does stage of resected EGFRm NSCLC impact your treatment decisions for use of adjuvant osimertinib?
Yes, to some degree; it informs the risk/benefit ratio when I discuss adjuvant osimertinb with patients. The benefit of adjuvant osimertinib was seen in stages 1B, 2 and 3 but the magnitude of the benefit increased with higher stages. This makes sense because the risk of recurrence increases with in...
For patients with early stage resected giant cell lung cancer and other less common histologies, are there any specific considerations for adjuvant therapy?
Giant cell carcinomas/pleomorphic carcinomas/sarcomatoid carcinomas are difficult, and typically aggressive entities. In reviewing the literature, there is precious little data to guide the selection of cytotoxic chemotherapy (most reports are pathology studies, some case reports, and unfortunately,...
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 ...
Should we delay adjuvant breast radiotherapy for early stage breast cancers as the COVID-19 situation evolves?
This is a very tough question given the unprecedented nature of this pandemic and the fact that its duration is unknown. Recommendations will likely vary based on the density of cases in a specific geographic location and will undoubtedly change frequently given the rapidly evolving nature of this s...