Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When using conventionally fractionated breast RT, does one need to treat the whole breast to 50Gy or is 45Gy, followed by a boost satisfactory?
One of the reasons why hypofractionation schedule appears to have less acute and late morbidity in comparison to 50 Gy is because of lower equivalent total dose ( about 46 Gy equivalence). Besides the data is mostly on central axis dose homogeneity rather than 3D dose homogeneity and for that reason...
What is your current practice for de-escalation of frequency of administration of bispecific antibodies among responders in patients with relapsed/refractory multiple myeloma?
This is a great question. Since the majority of patients respond, I'm not clear of the PFS benefit derived from maintaining dose intensity in patients with ≤ partial response. The majority of the data regarding de-escalation is from single-arm or registration trials that were not designed to discove...
How would you treat a patient with rectal cancer with a solitary lung metastasis, who now has no evidence of disease after total neoadjuvant therapy followed by rectal surgery and resection of the solitary metastasis?
Surveillance! Assuming this patient received “complete” total neoadjuvant therapy with at least 3-4 months of systemic therapy, preoperative radiotherapy to the pelvis and curative intent operations to the pelvis and lung with no evidence of residual disease on post-op imaging- this is the early out...
Does a negative staging PSMA PET in a patient with biopsy-proven recurrent prostatic adenocarcinoma change your management?
The bottom line is that you have to believe the biopsy. PSMA PET will not show microscopic disease, which is why it cannot "rule out" disease in lymph nodes or elsewhere. It is comforting when it is negative, but it is not absolute truth. A few questions; What was the PSA at the time of the PSMA PET...
Would you treat elderly patients with early-stage gastric cancer with perioperative FOLFOX or FLO (FLOT without T)?
I am actually not sure why the official FLOT regimen used a 24-hour 5FU infusion. In the progression from the Mayo 5-day bolus regimen and the Roswell Park weekly regimen, the use of infusional 5FU reduced the toxicity of combinations with oxaliplatin and irinotecan. See the NCCTG N9741 study (Goldb...
Is it safe to give thoracic irradiation to a patient with lung cancer previously treated with a VEGF inhibitor?
We did a study in patients getting VEGF inhibitors and SBRT. Anecdotally we had seen some impressive (small bowel necrosis requiring surgery) and unpredicted toxicity and we were looking for a common factor that tied them together. VEGF inhibition was that common factor. These are all patients treat...
In oligometastatic NSCLC with a solitary brain metastasis and lung primary amenable to SBRT, how would you sequence first-line systemic therapy versus local therapy to the lung after treatment of the CNS metastasis?
Would generally favor appropriate first-line systemic therapy whether that be immunotherapy +/- chemo vs. targeted therapy and if at least stable disease at the next surveillance imaging (~3 months), go ahead and consolidate with SBRT. I don't think it would be wrong to do SBRT upfront here but the ...
With the data from AALL1731, how is blinatumomab being implemented for SR and HR leukemia patients not previously planned/randomized to receive blinatumomab?
We have incorporated blinatumomab for most patients as two non-consecutive cycles. Once in maintenance, we have not uniformly added blinatumomab, although we have interrupted maintenance to offer blinatumomab to select patients (high-risk genetics or those who had significant treatment modifications...
Would you combine sutimlimab with bendamustine rituximab for cold agglutinin disease if patient continues to hemolyze during treatment?
In my experience, virtually all patients with true cold agglutinin disease respond to sutimlimab quite quickly. While there may be sub-clinical evidence of hemolysis for some time, generally hemoglobin improves to normal or close to this. Adding therapy to sutimlimab really depends upon the clinical...
Would you combine sutimlimab with bendamustine rituximab for cold agglutinin disease if patient continues to hemolyze during treatment?
In my experience, virtually all patients with true cold agglutinin disease respond to sutimlimab quite quickly. While there may be sub-clinical evidence of hemolysis for some time, generally hemoglobin improves to normal or close to this. Adding therapy to sutimlimab really depends upon the clinical...