Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
How does neoadjuvant chemo-immunotherapy impact your decision on hypofractionation/dose fractionation for locally advanced NSCLC, now getting RT alone?
If a patient has already received 3-4 months of a platinum-doublet chemotherapy during the chemo-immunotherapy phase, then it's always my preference to omit further chemotherapy and recommend RT alone. The rationale for this recommendation is that we don't administer additional chemotherapy to patie...
Are there any contraindications to Pluvicto therapy you personally use, given that there are none directly provided by the manufacturer?
In this situation, it is helpful to review the eligibility and exclusion criteria from the VISION protocol directly. These can be found at NCT03511664 (Sartor et al., PMID 34161051). Many of these patients have been heavily pretreated, including prior taxane therapy, so my main concern is that they ...
What is the role for chemoimmunotherapy in the up front setting in non-metastatic head & neck cancer outside of clinical trials?
Phase III studies of immunotherapy concurrent with chemo-RT vs chemo-RT alone, JAVELIN Head and Neck 100 and KEYNOTE-412, didn’t demonstrate a survival benefit of the immuno-containing regimens (while post hoc analyses suggested that PD-L1 positive patients may have benefited). These studies did not...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
How do you sequence targeted therapy and immunotherapy in patients with metastatic lung adenocarcinoma with EGFR exon 20 insertion mutations?
EGFR insertion 20 mutations are a rare subset of adenocarcinoma (1-2%). Patients with disease characterized by these mutations do not respond to EGFR TKIs such as osimertinib. Until recently, the standard first-line therapy for such patients was chemotherapy alone, typically carboplatin/pemetrexed. ...
Would you offer additional radiation in a young patient with T4N1 rectal cancer, s/p TNT and pelvic exenteration with a positive deep margin without gross disease seen on post-operative imaging?
This is a very difficult decision. Although somewhat arbitrary, it is considered desirable to have at least a 6-month interval, preferably a year, before considering re-irradiation. For a patient who had surgery following TNT, the interval since the first course of radiation is presumably only a few...
What role, if any, does systemic therapy have in the treatment of HCC amenable to definitive locoregional therapy?
Systemic therapy currently has no established role in patients with hepatocellular carcinoma (HCC) undergoing potentially curative locoregional therapy, including surgical resection or ablation. Active surveillance remains the standard of care after curative-intent treatment, and no perioperative sy...
How would you manage T3N0M0 sarcomatoid carcinoma of the prostate with adenosquamous differentiation s/p prostatectomy?
Sarcomatoid prostate cancer is an aggressive histological subtype. It may be locally aggressive, and post-operative PSA monitoring may be less helpful for this histologic subtype, which interferes with the usual trigger for initiation of salvage RT (Grignon, PMID 14976541). Despite the lack of high-...
When do you start ADT for a patient with a new diagnosis of node positive prostate cancer receiving radiation?
I would reverse the question order. For node-positive disease, I start ADT once staging imaging is complete. If logistically practical (as with high-risk localized), I often perform the simulation and start ADT at the same time, then start RT without a neoadjuvant period. Evidence for neoadjuvant AD...