Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there value to OncoType Dx and/or NGS testing for mutations such as ESR1 in patients who have ipsilateral isolated resectable skin recurrence in ER+ positive low Oncotype breast cancer 10 years after mastectomy and adjuvant AI for 5 years?
I would not order an Oncotype on this tumor if it is a delayed locoregional chest wall recurrence. These LRR events are at higher risk of distant disease and we don't have data on how prognostic or predictive the ODX score is in these scenarios. NGS is also of limited utility but may be helpful if a...
For a patient with localized high risk prostate cancer with high risk Decipher score receiving ADT and abiraterone, is there any value of continuing ADT and abiraterone beyond two years?
Since the trial (STAMPEDE) stopped abi at 2 years, that is the longest duration that I use.In the mHSPC setting, we are seeing many patients stay on their first-line treatment for many years (often longer than 2 years). This has made me more cognizant of the long-term effects of abi/prednisone (acce...
Do you routinely use a bone modifying agent in patients with metastatic RCC with bone metastases receiving a TKI?
Agree. For the most part, I don’t use BMA to treat bone mets as there is a lack of data/representation of RCC patients in BMA studies in solid tumors. With that said, I’ve discussed it in selected cases with disseminated bone mets. Differently, I do offer BMA to treat osteoporosis/osteopenia based o...
When you use selinexor for relapsed/refractory myeloma, with what total weekly dose do you practically start?
The answer is it depends. For most older or more frail adults, I would start at 60 mg weekly. For more robust, 80 mg weekly. More important, is whether I am combining with another anti myeloma agent other than steroids. In that case, I typically stick with 60 mg weekly. This helps not only with non-...
How do you treat colorectal cancer with heterogeneous loss of mismatch repair protein expression?
My approach, broadly, for stage IV (nonsurgical) patients is to try to treat with IO agents, and then address tumors that may not be responding (SBRT, ablation, etc) down the road (presumably those that aren't as sensitive to IO). The other option would be to use something like FOLFOX+checkpoint inh...
How do you integrate surgery in treatment of recurrent tenosynovial giant cell tumors (TGCT) when using Pexidartinib?
This is an interesting question, but one that has little (if any) data to guide management. With recurrent TGCT, the patient presumably already had surgery. It is possible that a good response to pexidartinib may reduce the morbidity of a repeat surgery but the risk of additional recurrence would re...
When and how would you consider utilizing checkpoint inhibitor immunotherapy in EGFR mutated metastatic lung cancer?
I typically reserve checkpoint inhibitors as a last resort treatment option in patients with EGFR mutant non-small cell lung cancer. I have used the IMpower150 regimen on several occasions, though we now have multiple datasets confirming the generally minimal benefit from immunotherapy for patients ...
Are there any risk factors for IO induced rhabdomyolysis and how do you approach and manage it?
IO can affect the muscle in many ways. There is a myasthenia gravis and myositis overlap. I am not sure we know whether it is rhabdomyolysis versus a CK leak vs steroid myopathy vs muscle necrosis due to something else. Did the patient have EMG or muscle biopsy? There is a lot we do not understand a...
What would your approach be for a patient with early stage gastric cancer who declines a gastrectomy?
I would first clarify if less invasive endoscopic or operative strategies such as endoscopic resection (EMR vs ESD) or local resection/partial gastrectomy are appropriate and feasible based on the patient and disease related factors. If not, I’d recommend definitive chemoradiation, 50-50.4 Gy in 25-...
In a patient with otherwise low-risk prostate cancer, does presence of a small component of Grade Group 3 disease up-stage to unfavorable intermediate?
I agree with Dr. @Dr. First Last's response and will just add a couple of additional thoughts. There are many things that go into making a decision about whether treatment is necessary, and what type of treatment is performed. In this case, it's important to consider patient factors (i.e. age, co-mo...