Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you choose between Atezolizumab/Bevacizumab (IMbrave 150) versus Durvalumab/Tremelimumab (HIMALAYA) versus Ipilimumab/Nivolumab (Checkmate09DW) in first-line metastatic hepatocellular cancer?
I use a range of factors, discussed here and here, when deciding between atezo/bev and STRIDE regimens in my patients with advanced HCC.Summarily, both regimens demonstrated clinical benefit in patients with advanced HCC with side-effect profiles expected for the individual agents. The choice of reg...
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...
What is the role for chemoimmunotherapy in the up front setting in non-metastatic head & neck cancer outside of clinical trials?
Phase III studies of immunotherapy concurrent with chemo-RT vs chemo-RT alone, JAVELIN Head and Neck 100 and KEYNOTE-412, didn’t demonstrate a survival benefit of the immuno-containing regimens (while post hoc analyses suggested that PD-L1 positive patients may have benefited). These studies did not...
In a patient with inflammatory triple-positive breast cancer who has a pCR to neoadjuvant chemotherapy, but has an incidentally found focus of intermediate-grade ER+/PR+/HER2- ILC in the mastectomy specimen, how would this impact your adjuvant radiation recommendations?
This finding would not have any impact on my recommendations, since her management needs to be guided by the inflammatory breast cancer. That means chest wall plus nodal irradiation tailored to the findings of axillary surgery. There are no data on whether we can decrease the dose in patients with a...
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
Would you consider definitive chemoradiation for small cell lung cancer that would otherwise be limited stage but has a solitary brain metastasis at presentation?
At the risk of sounding old-fashioned, a brain metastasis in a small cell lung cancer patient still makes them extensive, that is, stage IV. The standard of care for stage IV/extensive stage small cell lung cancer is systemic therapy and immunotherapy followed by immunotherapy consolidation, with ra...
Do you need renal biopsy before SBRT for RCC suspicious cancer?
Yes. The teaching is usually that ≈ 20% of small renal masses (<4 cm) are benign, and this rate goes down as size increases (Thompson et al., PMID 19286217). Features such as contrast enhancement, tumor location, and sex can help to improve the malignant risk potential of these lesions, but no combi...
Would you recommend adjuvant immunotherapy after platinum-based chemotherapy for patients with in resected NSCLC with HER2 mutations?
The benefit of immunotherapy in HER2 mutant NSCLC is an active topic of debate. I do not typically recommend adjuvant immunotherapy after platinum-based chemotherapy for patients with resected HER2-mutant NSCLC. Tumors with oncogenic drivers, specifically EGFR, ALK, ROS, RET, and HER2, show reduced ...