Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are there patients for whom CROSS followed by surgery and adjuvant nivolumab should still be considered, following data from MATTERHORN and ESOPEC?
ESOPEC does not invalidate CROSS—it redefines the preferred option for fit patients; in the real world, not every patient will be able to tolerate FLOT or d-FLOT: Yes. Despite the emergence of perioperative FLOT-based strategies from ESOPEC and MATTERHORN, CROSS, followed by surgery and adjuvant niv...
How many days do you hold osimertinib during or around SBRT for oligometastatic EGFR mutated advanced lung cancer?
This a great question and a common clinical scenario that we are all confronted with. Stereotactic body radiation therapy (SBRT) is being increasingly used for oligometastatic progression of EGFR mutant NSCLC. The theoretical risk of combining EGFR inhibitors and radiation therapy would be an enhanc...
In the high-risk adjuvant or metastatic setting when you initiate patients on ovarian suppression with the plan to start an AI, what protocol do you follow in terms of rechecking estradiol?
This is an area of intense interest, as well as uncertainty. In truth, unless the patient does not have a uterus, (unusual in premenopause) I typically follow clinical menses and have not followed estradiol.
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
Would you consider using bevacizumab/atezolizumab in HCC patients who received TKI in the first line?
This is a great question. After failure of a front-line single agent TKI, I would still favor the current FDA-approved agents: regorafenib; cabozantinib; ramucirumab in AFP-high; OR immunotherapy (nivolumab, pembrolizumab, OR nivolumab plus ipilimumab). It is important to note that the second-line ...
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...
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...
Are there any biomarkers that might indicate who might be responders to atezolizumab/bevacizumab for HCC?
Not at this time. Some preliminary studies are being done as ad hoc at this point and was not pre specified before the IMbrave study launching
Is there an absolute PSA level above which you would not recommend a radical prostatectomy for newly diagnosed prostate cancer despite the absence of metastatic disease with advanced imaging?
There is no absolute PSA level that would preclude radical prostatectomy in the absence of metastasis on staging imaging. However, I would explain to the patient that the chance of occult metastatic disease and the need for additional treatment after prostatectomy increases as the PSA increases. I w...
Would you offer adjuvant chemotherapy, or osimertinib if EGFR+, to patients with two synchronous stage 1A lung cancers that appear to be distinct and have both been resected?
Probably not. The cure rate for stage IA adenocarcinoma is 75-90%, depending on the details (including size). The ADAURA trial demonstrated a substantially improved DFS favoring osimertinib over placebo for patients with stage II or III NSCLC with an activating EGFR exon 19 or 21 mutation. Although ...