Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you adjust the steroid dose for steroid-induced psychosis in a patient being treated for secondary HLH with the HLH-94 protocol?
If disease status allows weaning, we slowly wean per recommendations in HLH94. If they need steroids because of significant hyperinflammation that is damaging, then we add risperidone, which generally works very well.
Given recent OS data from the OlympiA trial, would you offer adjuvant olaparib to a BRCA+ patient with pT1bN0 TNBC?
I would not, as those patients were not included in OlympiA.
Would you continue pembrolizumab in a patient with BCG-refractory NMIBC with CIS who has a negative surveillance cystoscopy (including random biopsies) but positive urine cytology?
More important priority at this point is to evaluate the positive cytology. If the random biopsies were done with white light cystoscopy only, I would consider blue light and repeat biopsies and would also evaluate the upper tracts and prostatic urethra.
How long would you continue trastuzumab for a patient with metastatic HER2+ esophageal adenocarcinoma whose tumor has achieved CR with FOLFOX + trastuzumab and has been disease-free for nearly 3 years?
This is an important question and one that we are thankfully much more likely to have to address than ever before. I think that slightly more contemporary iterations of this question can be asked for a patient with a Her2 positive, PD-L1 CPS >1 tumor who has received pembrolizumab/trastuzumab and FO...
Is there still a role for mTOR inhibitors in metastatic RCC in the immunotherapy/TKI era?
Practically all my patients with metastatic clear cell RCC will receive an mTOR inhibitor at some time during their treatment course unless they achieve durable CR with early therapy lines. It is a plausible pathway to target, often well tolerated, and very rarely (one in hundreds) may produce durab...
What dose and fractionation would you recommend for a localized primary bone marginal zone lymphoma?
This would be an unusual presentation for marginal zone lymphoma (MALT lymphoma) and not one I've actually encountered. In a large series from MSKCC, "soft tissue/bone" comprised 2% of cases treated with radiation therapy (IJROBP 2015;92:130). Case series from Princess Margaret (Cancer 2010;116:3815...
Would you recommend PARP inhibitor maintenance for a patient with HR-proficient ovarian cancer with no targetable mutation, but with a favorable KELIM score and a significant clinical, radiographic, and serological response to platinum-based chemotherapy?
To date, the clinical trials that have included biomarkers for response to PARP inhibitors have shown that those with BRCA pathogenic variants appear to have the largest benefit followed by those with HRD tumors; however, these do not account for all the individuals who have disease that could benef...
With immunotherapy now often being used in the first-line setting for advanced endometrial cancer, what is the role of immunotherapy in the second-line?
This is a relevant and important question that we have yet to definitively answer. Furthermore, it may depend on several factors such as progression while receiving front line maintenance immunotherapy versus progression after completion of maintenance treatment, or progression after discontinuation...
In patients with HCC and asymptomatic but endoscopically visible varices, how long do you wait to start bevacizumab after banding?
That is an excellent question and one that does not have a clear answer to date. In these situations, timing of bevacizumab initiation depends on the patient's risk of bleeding and often is a discussion between oncology and a skilled endoscopist. We typically wait ~3-4 weeks after an intervention fo...
How would you treat a potentially resectable stage III lung adenocarcinoma with an EGFR mutation?
How would you treat a potentially resectable stage III adenocarcinoma with an EGFR mutation? Do you consider any neoadjuvant therapy or proceed to surgery followed by adjuvant chemotherapy and osimertinib? This is a very challenging patient scenario that we face with some frequency and it truly is l...