Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach systemic therapy for a patient with HPV-unrelated recurrent/metastatic head and neck squamous cell carcinoma who has progressed on both a platinum-based regimen and immune checkpoint inhibitor therapy?
I typically look for clinical trials in this space. Thankfully, there are a few options coming up for second line therapy. Outside of a trial, single agents such as cetuximab or capecitabine or docetaxel or MTX have been used with some response rates, but no consistent survival benefit. Therefore wh...
For a patient with ICI toxicity who is resistant to the use of high-dose steroids, are there scenarios where you would consider the use of first-line conventional synthetic DMARD in place of steroids?
Loaded question — I think we need a reframing of ICI-toxicity, much of the ICI side effects are just an autoimmune reaction in a specific organ. High doses of steroids are used if there is a true risk for organ damage (like when you have acute ANCA vasculitis, lupus nephritis, etc.). So if a patient...
What approach is suggested for extended adjuvant endocrine therapy in a HR+ breast cancer?
This can be a complicated decision for which you need to take into consideration the patient's estimated risk of late recurrence, her understanding of that risk, how well (or poorly) she has tolerated the first 5 years of adjuvant endocrine therapy, and her age and comorbidities, including the prese...
Given results of the RADICALS trials, is LT-ADT standard of care for salvage prostate RT?
I do not think long-term ADT is established as standard of care for salvage prostate radiation, as this would require a demonstration of improved overall survival in at least specific subgroups of patients. RADICALS-HD demonstrates improvement in freedom from metastasis as well as freedom from non-p...
What criteria do you use in deciding whether or not to treat the pelvis in prostate cancer?
NRG/RTOG 0924 - The end of elective nodal RT in localized prostate cancer? Top line results: NRG/RTOG 0924 is a very large phase III randomized trial powered for overall survival (OS) to determine if there is a benefit of the addition of whole pelvic radiotherapy (WPRT) to prostate RT plus ADT. This...
How would the updated results of ECOG 3311 influence your adjuvant RT recommendations for HPV+ OPSCC?
This question refers to this manuscript (Burtness et al., PMID 40493877), which is a 4.5-year follow-up of ECOG E3311.The results broadly mirror those seen in previous reports. The most notable novel finding reported is that among patients with low-risk features (who did not get any adjuvant RT), th...
How would you manage a patient less than 40 years old with an incidentally found LGG, IDH mutated, 1p19q intact, s/p STR?
Update: On August 6, 2024, the FDA approved Vorasidenib for IDH-mutant low-grade gliomas based on findings from the INDIGO trial. This decision highlights the FDA's incompetence and lack of scientific integrity, clearly demonstrating that the agency prioritizes pharmaceutical companies' interests ov...
In a patient with pancreatic carcinoid s/p resection with positive margins do you recommend surveillance or adjuvant therapy?
Well-diff and by small size (<1 cm), NCCN guidelines would have said watch this from the start, so certainly wouldn't recommend any adjuvant therapy at this time for positive margin resection. Margin status has been shown not to be associated with overall survival outcomes, particularly for low-grad...
Which types of pancreatic cancer patients should we consider sending to a center that offers EUS-guided Radiofrequency Ablation (RFA) therapy?
EUS-guided ablation for appropriately selected mucinous pancreatic cysts and, to some degree, neuroendocrine tumors is becoming increasingly standardized with multiple reviews on the subject. (Rodger et al., Techniques and Innovations in Gastrointestinal Endoscopy 2024, Moyer & Canakis, PMID 3879629...
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...