Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a patient with good-risk stage III pure seminoma who has an excellent response to first-line chemotherapy, including normalization of tumor markers and resolution of measurable disease, but has a persistent pleural effusion with cytology showing rare malignant cells consistent with seminoma?
This is not a pattern or behavior of seminoma that I have seen. My first thought is that I would probably not do anything but observe him at this point. I am concerned that the cytology finding is not accurate. There is no penalty for waiting. If he has persistent disease, he will declare that soon ...
In mCRPC patients who had an initial response to Pluvicto but progress within 12 months, where do you position PSMA radioligand retreatment relative to other next-line systemic options in your sequencing strategy?
After Lu-PSMA therapy, we may consider taxane chemotherapy, Ra-223, ARPI, or clinical trials in addition to Lu-PSMA retreatment. Retreatment may be more heavily considered in patients with prior deep response to Lu-PSMA, high avidity on a repeat PSMA PET, and/or limited candidacy for other treatment...
When do you start adjuvant radiation with areas of delayed wound healing after reduction mammoplasty?
Great question. I have cared for many patients with delayed healing post-lumpectomy (e.g., from infection, wound failure, etc.), and that experience is likely pertinent to the mammoplasty setting. Once the wound is open, it is going to take many weeks/months to “fully” heal, and it is not practical...
What would be your next line of therapy for a postmenopausal metastatic ER+/Her 2- BC, s/p anastrazole and palbociclib/fulvestrant who has progressive disease and ESR1 mutation on ctDNA?
For this postmenopausal metastatic ER+/HER2-negative breast cancer patient, progressing after anastrozole and palbociclib/fulvestrant with an ESR1 mutation, elacestrant, imlunestrant, or vepdegestrant monotherapy are all appropriate ESR1-directed options. Elacestrant has the longest track record and...
Does receipt of chemoimmunotherapy for LS-SCLC impact your recommendation for PCI?
Historic data showed that the addition of PCI for patients with limited-stage small cell lung cancer showing response after chemoradiotherapy improves overall survival and decreases brain failure rates by about 50%. Recently, the addition of consolidation immunotherapy after concurrent chemoradiothe...
What first-line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
For patients presenting with brain metastases, I always do local therapy, usually SBRT, before systemic therapy. I am nervous about starting immune-based therapy or a TKI in patients with uncontrolled CNS metastases. There are small series using TKIs such as cabozantinib in this setting, but since S...
Can an AYA patient with newly diagnosed AML safely sperm bank after starting cytoreduction with hydroxyurea or cytarabine?
Thanks for the question. Unfortunately, there is not a lot of data available to answer this question with certainty. Because of that, I err on the side of saying that this should not be done. The concern lies with the possible impact on the sperm DNA, and the subsequent effect that might have on a p...
How, if at all, are you modifying your practice and clinical workflow for patients receiving checkpoint inhibitors with data showing improved outcomes for patients receiving infusions earlier in the day?
The paper supporting the 'early morning' approach has been retracted, and arguments against this are being actively pursued for full publication. Recently, data were presented at AACR as well. The half-life of these molecules is quite long (in the range of weeks), which raises a question against the...
What's your follow-up protocol for a near complete response (nCR) in rectal patients considering non-operative management (NOM)?
This is a question that comes up in our colorectal tumor board routinely. For patients with a near-complete response after the completion of TNT, we recommend repeating an MRI of the rectum and endoscopic exam ~8 weeks later. If there is still a lack of complete response, our formal recommendation i...
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 ...