Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are your recommendations for holding bevacizumab before and after SBRT to the lung?
As @Maria Werner-Wasik notes, our experience at Memorial Sloan Kettering has indicated that giving SBRT for ultra-central lung tumors in a patient who has also been exposed to VEGF inhibitors may be an extremely dangerous combination associated with a high risk of fatal pulmonary hemorrhage. This wo...
How would you approach iron supplementation in a beta thalassemia trait patient with restless leg syndrome?
Thalassemia does not alter my decision. I don't use PO iron for RLS as it is enormously more toxic. A ferritin of 75 is a light-year away from iron overload, and a total dose infusion of IV iron can be administered with impunity. This patient should be treated with a gram of LMW iron dextran over on...
What third line treatment do you consider for a patient with metastatic pancreatic cancer with good functional status and no targetable mutations after progression on FOLFIRINOX and gemcitabine/nab-paclitaxel?
Sadly, there is absolutely no "standard" option in this space, as no trials have demonstrated any meaningful benefit. I personally would not just "try" a therapy - and I would especially not just "try" an immune checkpoint inhibitor, as these, as single agents have shown no benefit at all (if the tu...
What is your preferred sequencing of adjuvant chemotherapy and PMRT for node + breast cancer?
I addressed this issue for patients treated with breast-conserving surgery in May 2023; please see that answer for more details. To summarize, the toxicities from chemotherapy may be greater and its effectiveness reduced (at least for high-risk patients) when given after RT instead of before (Recht ...
Can trastuzumab deruxtecan be continued during radiation?
Data is limited, with the suggestion of higher necrosis with SRS. For other sites for palliation, I would not say it’s contraindicated, but caution needs to be exercised especially for the risk of increased lung and GI toxicity (because of independent toxicity from the drug and the potential for sen...
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 ...
How do the results of INSEMA and SOUND impact the decision of omitting SLND in young women with breast cancer and offering adjuvant RT to patients who would otherwise be candidates for omission?
Both trials required radiation so I would recommend it for a young woman not getting sentinel lymph node evaluation, and would lean toward whole breast irradiation. INSEMA required whole breast irradiation and SOUND allowed partial breast irradiation (10% of patients) but the majority of patients re...
What clinical or logistical factors influence your choice of anti-CD38 antibody in first-line treatment of multiple myeloma?
I generally use daratumumab, because subcutaneous is more convenient for patients, and we go to once-a-month dosing much quicker with daratumumab compared to isatuximab. Once isatuximab subcutaneous is available, this advantage of daratumumab may be lost, but given comfort and familiarity with darat...
What clinical or logistical factors influence your choice of anti-CD38 antibody in first-line treatment of multiple myeloma?
I generally use daratumumab, because subcutaneous is more convenient for patients, and we go to once-a-month dosing much quicker with daratumumab compared to isatuximab. Once isatuximab subcutaneous is available, this advantage of daratumumab may be lost, but given comfort and familiarity with darat...
How would you approach management of a large, fungating squamous cell carcinoma of the auricle if surgical management is not desired by the patient?
For a tumor this size and with cartilage invasion, I would recommend starting with induction cemiplimab to best response (generally 4-6 cycles), followed by consolidative RT, generally electrons. Prior to starting the immunotherapy, I would stage the neck with a contrast CT scan, as tumors of this s...