Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach treatment of a grade 4 IDH-mutant astrocytoma, a diagnosis now distinct from glioblastoma according to the 2021 WHO Classification for CNS Tumors?
This is an excellent question. The short answer is that until we have more data on this new entity, I would treat an IDH mutant (mt) grade 4 astrocytoma as I would have prior to the 2021 WHO revision, that is to say, with concurrent chemoradiation therapy and adjuvant Temodar for 6 cycles (or a clin...
Which patients with acute promyelocytic leukemia do you consider maintenance after completing consolidation?
Before we address the role of maintenance in APL, several principles are important to note. First, APL is now a highly curable disease with contemporary therapeutic strategies. Second, we now divide patients into low-risk and high-risk based solely on the presenting WBC (< or =10,000/uL vs >10,000/u...
How would you treat a patient with active lupus nephritis (class 3/4) who requires PD-1 immunotherapy for refractory metastatic renal cell carcinoma?
This is a complex question and there is a paucity of data to address it. The critical issues are of timing (new onset or existing nephritis, disease activity) and treatment regimen. Given that oncologists will not use checkpoint inhibitors on patients requiring more than 10 mg of prednisone at base...
Would you consider adding durvalumab to second-line chemotherapy for cholangiocarcinoma which progressed on gem/cis alone?
Yes. Data is needed, however, a scaffold approach maintaining durvalumab and adding different chemotherapies like NIFTY or FOLFOX as walls to the building frame of immunotherapy is appropriate and justified.
What treatment would you recommend for a patient with recurrent oligometastatic abdominal leiomyosarcoma, with two liver lesions?
I would ask for needle ablation. Leiomyosarcoma is unusual among cancers in that serial oligometastatic recurrence is not uncommon. These people can be managed with serial destructive therapy - resection, needle ablation, or radiosurgery. I have met people with LMS who have had many resections and a...
How do you define bone disease progression in mCRPC while on docetaxel?
Defining bone scan progression on docetaxel is no different than in other treatment contexts and generally, I use PCWG2-3 criteria. I generally do not stop docetaxel in the first 4 cycles based on PSA changes alone since transient PSA rises followed by falls can occur during these first 3 months. Ho...
Would you offer adjuvant therapy of any kind to a patient with synchronous primary lung cancers if all early stage and curatively treated?
Personally, I would not. However, this assumes that we are convinced that these are distinct early stage lung cancers. I would advocate for NGS testing of each tumor to ensure these are not actually sites of metastases. If truly distinct early stage cancers, then would treat with surgery/radiation a...
How would you approach a T3N1M0 mid rectal cancer that is MMR deficient?
About 2.7% of rectal adenocarcinoma are mismatch repair deficient (dMMR) (Papke Jr. et al., PMID 36322852) and locally advanced dMMR rectal cancers have a great response to immunotherapy. Six months of single agent Dostarlimab led to 100% complete clinical response in the phase 2 study including 14 ...
When do you perform a kidney biopsy in a patient with AKI that is thought to be related to an immune checkpoint inhibitor?
I would wait for the response to corticosteroid therapy before the renal biopsy.
Would you drop the duration of palbociclib from 1-21 days to 1-14 days if still neutropenic with 75 mg dose in metastatic breast cancer?
I have seen various "off protocol" solutions that oncologists use, probably with the idea that "some is better than none" (which is often true but hard to know how much benefit in a data free zone). Anecdotally, I've seen: every other week therapy; 3 weeks on and 2 weeks off; and finally 5 days on w...