Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What criteria are you using for retreatment with Pluvicto (Lu-177) in those who maintain a good performance status and appropriate lab work?
Mainly, whether or not they've exhausted standard options. At the time I'm answering this, Pluvicto is approved for castration-resistant metastatic disease, either pre- or post-taxane chemotherapy. If they have not had chemo, I usually recommend it. If they have, I get their medical oncologist to we...
What therapy do you usually choose in patients with previously treated follicular lymphoma who experience early relapse (<2 years)?
My approach to POD24 patients is to first ensure there is no evidence of transformed disease. According to a retrospective analysis led by @Dr. First Last at Memorial Sloan Kettering, as many as 40% of the POD24 patients have evidence of transformed disease if a biopsy is pursued. Clinical indicator...
What therapy do you usually choose in patients with previously treated follicular lymphoma who experience early relapse (<2 years)?
My approach to POD24 patients is to first ensure there is no evidence of transformed disease. According to a retrospective analysis led by @Dr. First Last at Memorial Sloan Kettering, as many as 40% of the POD24 patients have evidence of transformed disease if a biopsy is pursued. Clinical indicator...
How do you decide between checkpoint monotherapy versus chemo-immunotherapy approach for patients with PD-L1 High (>50%) NSCLC?
At this point, there are no prospective trials comparing checkpoint monotherapy and chemo-immunotherapy for patients with PD-L1 high NSCLC. The ongoing prospective INSIGNA trial will answer this question. If one does a cross trial comparison of pembrolizumab for patients with PD-L1 of >50% and chemo...
In a patient with de novo stage IV breast carcinoma harboring an RB1 Q395* (nonsense) mutation, would treatment with a CDK4/6 inhibitor be appropriate, or should it be avoided due to likely resistance?
HR+/HER2- with baseline RB1Q395* nonsense mutation. This is one of those incredibly tough, "data-free zone" scenarios where standard guidelines fail us, and we have to rely heavily on clinical judgment and the underlying biology. In a de novo metastatic setting, our reflex is always to reach for a C...
In light of recent updates on neoadjuvant enfortumab vedotin plus pembrolizumab for muscle-invasive bladder cancer showing benefit, how should a trimodality bladder-preservation strategy be contextualized?
The treatment of muscle-invasive bladder cancer. has evolved quickly. Neoadjuvant EVP is absolutely the standard of care in all patients who can receive it. The clinical trials (EV-303/304) used cystectomy as the bladder-directed therapy, and this is the standard of care. Having said that, many pati...
Would you consider utilizing pembrolizumab/enfortumab as a bladder preservation approach in patients with MIBC?
Yes, I think that this is a viable approach. Data from perioperative trials, including KN-905 and EV-304, suggest very high rates of pathologic complete responses in almost two-thirds of all patients at the time of radical cystectomy. Many of these patients may not need radical cystectomy for an opt...
How do the results of KEYNOTE-B15/EV-304 influence your preferred treatment for cisplatin eligible MIBC?
The management of urothelial cancer has undergone major changes in the last decade.We have seen a number of new drugs approved for relapsed BCG-refractory superficial bladder cancer. Additionally, we have seen a number of new approaches for the management of muscle-invasive bladder cancer (MIBC) or ...
Would you recommend sentinel lymph node biopsy at the time of wide excision for a 3 mm Merkel cell carcinoma of the cheek/lateral canthus?
Unlike melanoma and certainly NMSC, MCC is highly unpredictable in nature, with clinical lesion size having little clinical prognostic value. As such, it appears that SLNB is valuable in many cases for the purposes of prognosis and in determining the need for adjuvant systemic therapy and radiation....
What are best practices for medical oncology clinics during the COVID-19 pandemic?
Agree with @Dr. First Last's response. Here are some of our guidances (with the caveats that there are exceptions to all of these, and they are dependent on clinician-patient discussions): Patients with active COVID-19 infection Delay/stop oncologic therapy (chemotherapy, radiation, surgery) until ...