Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a patient considered to be unfit for cystectomy with recurrent NMIBC refractory to BCG, failed pembrolizumab and unable to do more intravesical Rx?
This seems to be a very difficult scenario, what are the reasons for not being able to pursue intravesical therapies? Nadofaragene firadenovec just got FDA approval, while there have been data with intravesical gemcitabine/docetaxel. We are waiting for the FDA decision on N-803/BCG combo (QUILT-3.03...
Would you consider bone antiresorptive therapy in mCRPC with only 1 lesion per PSMA scan?
This is an important question. One of the best studies to examine this is here:Francini et al., PMID 34292336 from the abiraterone chemo naive mCRPC multicenter cohort study, in which both survival and SRE free survival were improved with the use of bone resorption inhibitors, especially in men with...
How would you treat a patient with chronic phase CML who could not tolerate nilotinib due to G4 thrombocytopenia despite sequential dose reductions?
It depends on various other factors such as the current response and the doses used. I generally work on trying to get the patients to tolerate treatment first and then focus on response. I have used doses of nilotinib as low as 50 mg daily in some patients; this may make the thrombocytopenia more m...
Would you offer neoadjuvant chemoimmunotherapy to a woman with clinical T3 N0 M0 triple negative metaplastic breast cancer?
Yes, assuming she is fit, I would offer this patient the neoadjuvant KEYNOTE-522 regimen of multi-agent chemo + immunotherapy. To my knowledge, there is no high quality evidence to suggest that metaplastic tumors should be treated differently than standard histology triple-negative tumors (though we...
What are your top takeaways from ASH 2022?
1. Late Breaking Abstract (LBA-1): Consolidation Therapy with Blinatumomab Improves Overall Survival in Newly Diagnosed Adult Patients with B-Lineage Acute Lymphoblastic Leukemia in Measurable Residual Disease Negative Remission: Results from the ECOG-ACRIN E1910 Randomized Phase III National Cooper...
How long after initiating ADT/androgen blockade is it acceptable to start docetaxel in a patient with high burden, de-novo metastatic HSPC where you are recommending triplet therapy?
In ARASENS, patients were allowed to enroll if they had received no more than 3 months of ADT prior to starting docetaxel +/- darolutamide. The biologic underpinnings suggest that the combination is most likely to be effective if given together. Therefore, I generally prefer to start the patient on ...
Would you consider a PARPi for a patient with PALB2 mutated metastatic triple negative breast cancer?
PARP inhibitors currently have FDA approval for treatment of breast cancer in patients with HER2 negative disease who carry a BRCA 1 or BRCA 2 mutation, but not other familial (germline) genetic mutations and they are not approved for tumor (acquired) genetic mutations. Theoretically, PARP inhibito...
How would you manage a premenopausal patient with HER-2 positive DCIS in the setting of a prior HER-2 positive contralateral breast cancer?
NSABP B-43 looked at the combination of post-op RT + trastuzumab vs RT alone in HER2+ DCIS and while there was a numerically lower number of IBTR events in the trastuzumab arm, this did not reach statistical significance. At this time, we do not manage our HER2+ DCIS patients differently than HER2-....
What is your approach for using anticoagulation/aspirin in patients with multiple myeloma?
Excellent question with lots of nuances but no clear answer. I'll start with my gestalt approach, which is to consider a DOAC for every patient with myeloma if all of the following are true: They are receiving an IMiD (lenalidomide or pomalidomide) They set off my 'spidey sense' with one or more of ...
What is your preferred management for diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)?
The management of patients with DIPNECH is predominantly symptomatic but DIPNECH is a chronic disease, often with significant respiratory symptoms such as dyspnea and cough but the severity of the symptoms varies over time.I recommend involving pulmonary medicine early on as the management can resem...