Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant immunotherapy in a patient with high risk RCC with new/worsening post-op renal dysfunction and CrCl<30?
My preference in situations like this is to stabilize the renal function first. I am comfortable treating the patient with adjuvant pembrolizumab with a CrCl <30 mL/min but it should be stabilized first. That will make it easier to diagnose potential irAEs as compared to starting adjuvant treatment ...
What would be your next step in management for a patient with oligometastatic colon NEC who only achieved stable disease after 4 cycles of carboplatin/etoposide?
There are essentially 2 options here: 1) To take a therapy break; 2) To continue.Resection is only considered for highly selected cases of NEC and almost never for metastatic disease as early recurrence is the rule. I am not the only one who has noticed that the ORR and likely OS to platinum/etoposi...
Should radiotherapy be utilized in stage IVA NSCLC with a malignant pericardial effusion?
This has come up on occasions. I'm not aware of any high-quality evidence to guide one way or another. I would say, there may be a role for thoracic RT on a case by case basis. Though, I would preface all of this by stating that malignant pericardial effusion usually confers a poor prognosis.I assum...
Would history of breast cancer deter you from using ospemifene for severe vaginal dryness/dyspareunia?
The agonistic/antagonistic activity of ospemifene in different tissues that express estrogen receptors is incompletely understood and therefore, I would have reservations about using this agent in women with hormone receptor positive breast cancer. In fact, looking at the labeling information of osp...
With the recent approvals of CAR-T for second-line therapy in myeloma, does this change your approach to use of consolidative autologous transplant or autologous transplant as second line therapy?
This is an excellent two-part question, and hopefully one where we'll continue to see more data year by year!The second question (ASCT as second-line therapy) is easier to answer - in brief, I no longer recommend this. Extrapolating from first-line consolidation to second-line salvage ASCT (i.e., f...
With the recent approvals of CAR-T for second-line therapy in myeloma, does this change your approach to use of consolidative autologous transplant or autologous transplant as second line therapy?
This is an excellent two-part question, and hopefully one where we'll continue to see more data year by year!The second question (ASCT as second-line therapy) is easier to answer - in brief, I no longer recommend this. Extrapolating from first-line consolidation to second-line salvage ASCT (i.e., f...
How do you approach adjuvant treatment of non-uterine leiomyosarcoma?
I do not offer adjuvant chemotherapy to persons with leiomyosarcoma. One can make a case that the large negative randomized study EORTC 62931 published in 2012 supplants the 2008 meta-analysis of smaller studies that showed survival benefit from adjuvant chemo. Woll et al., PMID 22954508Neither is t...
How would you approach adjuvant therapy for a patient with duodenal adenocarcinoma with ypT3 pN2 disease on Whipple resection after neoadjuvant FOLFOX x6?
I would offer postoperative chemoradiation. Duodenal primary cancers have more of a significant locoregional pattern of spread so logically, local control improvement could translate to a survival benefit.
Would you consider adjuvant osimertinib for patients with non-classical but sensitizing EGFR mutation positive NSCLC s/p surgical resection?
While uncommon, EGFR mutations were not included in the ADAURA trial (and thus may not be covered by 3rd party insurance), I will consider using osimertinib in the adjuvant setting for high risk patients with certain atypical/uncommon EGFR mutations, i.e. mutations wherein structure-based modeling a...
Is there a preferred chemotherapy regimen for chemo-mobilization prior to HDCT for a patient with NSGCT with prior BEP and TIP?
In general, at most high-volume institutions, there is little utilization of mobilizing chemotherapy prior to high-dose chemotherapy. Stem cell collections seem to be accomplished without standard dose chemotherapy in most cases.