Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
How would you treat a patient with stage 4 NSCLC with EGFR R776H mutation?
R776H is a rare exon 20 point mutation. Preclinical models suggest that it is an activating mutation and that it is sensitive to erlotinib, afatinib, and osimertinib [Kohsaka et al., PMID 30404555]. Several case studies of patients with rare EGFR mutations have reported responses to EGFR TKIs (erlot...
For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?
Continuous acalabrutinib has relatively low incidence of significant AE and does not require multiple prolonged infusion visits which is very appealing for frail patients. As well, available data would suggest that those with TP53 abnormalities (high genetic risk) do similarly to those without this ...
How do you recommend differentiating between localized cutaneous melanoma of the perianal skin versus mucosal melanoma of anal canal?
Although perianal melanomas arise within squamous epithelium, I think it is better to characterize these as mucosal melanomas. I think of it as being similar to melanomas that arise within the cutaneous surface (i.e. squamous epithelium) of the vulva but are still considered to be mucosal melanomas....
In a patient with metastatic TNBC on chemoimmunotherapy for several years and a near complete response, would you consider an immunotherapy holiday?
Hard to answer this question without understanding the context of the clinical scenario. In the scenario of chemoimmunotherapy, I would drop off the chemo and maintaining single-agent immunotherapy. If the patient has transitioned to immunotherapy alone, you can only use a maximum of two years (ate...
How would you manage a CLL patient who experienced severe infusion reactions with rituximab and has exhausted all other options?
This is a relatively common question and very relevant to clinical care. Rituximab, Ofatumumab, and Obinutuzumab do target CD20 but all should be viewed as we would view different structural classes of drugs. In general, if one has a very bad reaction to rituximab, depending upon what it is, one can...
How are you timing the third dose of the COVID-19 mRNA vaccine in patients on rituximab?
At this point, I am advising the patients to do the 3rd vaccine at least 5 months after the previous Rituximab dose. Whenever feasible, I test them for B cell reconstitution prior to vaccination, and may delay the vaccination if B cells are undetectable.
How would you manage early-stage low rectal cancer in a patient unable or unwilling to undergo surgery?
This patient may have multiple non-TME alternative options. Trans-anal excision with or without post-op CRT based upon pathological risk factors would be one option. Alternatively, CRT as part of a non-operative management/watch and wait strategy is also associated with favorable outcomes. Here are ...
How would you approach patients with resected, node positive (N1/N2) Large Cell Neuroendocrine Carcinoma of the Lung who have ESRD on dialysis?
This is certainly a challenging situation, both because of the relative scarcity of data for LCNEC in general as well as the limitations placed in patients with organ dysfunction including requirement of HD.First issue is the question of adjuvant treatment for LCNEC. The role of adjuvant chemotherap...
How would you manage a nodal recurrence of cutaneous SCC if the patient is unable to receive surgery for 6-8 weeks?
I’d first consider referring the patient to a center that could perform the operation, as it is standard of care for a patient with resectable cSCC with nodal metastases. At some centers, there may be a clinical trial of neoadjuvant immunotherapy that could be considered. If those options were not...