Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How long after lumpectomy for DCIS in a premenopausal patient can tamoxifen be started and still retain the benefit?
The TAM-02 trial showed that women with IDC who delayed taking tamoxifen 2 or more years after their diagnosis still did better than those who did not initiate it at all. You can extrapolate this data to ER+ DCIS as the protective benefit of estrogen blockade on breast tissue occurs whenever it is s...
How do you decide between systemic vs. arterially directed therapies in the first line setting for unresectable HCC?
In IMbrave150, 63% of patients treated with atezolizumab/bevacizumab had extrahepatic spread of disease, and my recommendation for patients with extrahepatic involvement is for first line systemic therapy. For patients with unresectable disease without extrahepatic spread, we take a multi-disciplina...
How would you manage a patient with a solitary plasmacytoma with a partial response to RT?
A solitary osseous plasmacytoma can be higher or lower risk than an extra medullary plasmacytoma; for instance, a tonsillar plasmacytoma is different than one in lung parenchyma. The largest study I know about evaluating solitary plasmacytoma of the bone involved 206 patients without evidence of mye...
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 ...
Which imaging modality do you prefer when monitoring disease status for patients with prostate cancer undergoing 177-Lu PSMA treatment?
At the present time, I generally use contrast-enhanced CT of the chest/abdomen/pelvis and whole-body Tc-bone scan (every 12 weeks) for monitoring. While it is attractive to consider serial PSMA-PET imaging for monitoring disease response to 177Lu-PSMA-617, there is currently no FDA indication to use...
For LS-SCLC with radiographic CR after chemotherapy, is there a time point beyond which you do not offer radiation if there is a delay in initiation of radiation?
I don't think we really have any data guiding this scenario. We know that optimal benefit is achieved when definitive RT is given within the first 2 cycles of chemo. However, I don't think that chemo alone is adequate for total eradication of disease. If the patient is within 1-2 mos of completing c...
Does the possibility of future Lu-177–PSMA therapy change your current threshold to offer earlier metastasis-directed RT in oligometastatic prostate cancer?
There is a lot of excellent research being done on the efficacy and tolerance of combined Lu-177-PSMA therapy and EBRT. So far, the combination is well tolerated, and there is some data that sequencing the two to allow EBRT to treat the more “Pluvicto-resistant” lesions may help with efficacy.The qu...
How do you approach the treatment of HSCT-associated thrombotic microangiopathy?
TMA can be due to multiple insults: If the patient is on tacrolimus or cyclosporine, the dose should be reduced. These drugs cause the renal afferent arterioles to spasm, and RBC fragmentation can occur on that basis. It typically responds to a dose reduction If the patient was conditioning with TB...
How do you approach the treatment of HSCT-associated thrombotic microangiopathy?
TMA can be due to multiple insults: If the patient is on tacrolimus or cyclosporine, the dose should be reduced. These drugs cause the renal afferent arterioles to spasm, and RBC fragmentation can occur on that basis. It typically responds to a dose reduction If the patient was conditioning with TB...
How do you approach treatment of 1p19q non-codeleted high grade gliomas?
The question focuses on the management of 1p19q non-codeleted high-grade gliomas, which for all practical purposes translates roughly to the entity that by legacy terminology has been referred to as anaplastic astrocytoma. This question has come into focus with the recent publication of results of t...