Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with metastatic HCC on atezolizumab/bevacizumab who requires holding bevacizumab due to persistent proteinuria >2g?
This is a great clinical question, one that we often see since the approval of atezolizumab/bevacizumab in first line setting for HCC. Incidence of proteinuria with bevacizumab has been reported anywhere from 0.8%-4% for grade 3 (more than 3.5 g in a 24-hour urine protein level) (Brandes et al., PMI...
For a Jehovah's Witness patient with multiple myeloma, could you safely offer a BCMA-directed bispecific antibody or CAR-T therapy?
Short answer is - yes! Long answer is - it depends. Patients can be optimized leading into CAR T-cell therapy by using ESAs and possible TPO agonists, iron, B12, folate supplementation. The main issue is around propensity for anemia and thrombocytopenia, especially if profound and prolonged. Patient...
Would you extrapolate from EMBARK to use an ARPI other than enzalutamide in high risk biochemically recurrent prostate cancer for a patient with contraindications to enzalutamide?
This is a good question and my general answer is no, as no other ARSI has a phase 3 trial in this nmHSPC setting showing similar benefits. PRESTO was a smaller phase 2 trial of ADT/apalutamide but did not measure or report MFS or OS and was underpowered to look at these endpoints. However if a patie...
Would you offer adjuvant osimertinib in a patient with complete pathologic response to neoadjuvant platinum doublet for a stage IIIA resected EGFR mutant lung adenocarcinoma?
With the caveat that we do not have level I evidence specifically for this clinical scenario yet (ongoing NeoADAURA study may potentially provide some answers in the future), based on very favorable outcomes of patients with NSCLC in general who derived pathologic complete response after neoadjuvant...
Is a bone marrow necessary in patient with splenomegaly and polycythemia vera?
Yes. Bone marrow is necessary in a patient with polycythemia vera and splenomegaly. There is a possibility of missing ET or associated primary or secondary myelofibrosis. The only way to distinguish between the three bcr-abl negative MPN namely MF, ET, and PV is by performing a bone marrow biopsy an...
How do you manage small oropharyngeal cancers with N1 or N2 disease?
For T1-2N1 oropharyngeal cancers there is data from MD Anderson and Toronto that they do quite well with RT alone. These patients are excluded from current RTOG chemo-RT protocols. It is possible that more advanced tumors that are HPV(+) in non- or remote smokers will also do very well with RT alone...
Do you ever give postoperative chemoradiation in patients who underwent preoperative chemotherapy for gastric adencocarcinoma?
This is not a particularly data-driven approach, as the MAGIC trial did not give post-operative chemoradiation (and most patients did not tolerate the planed post-operative chemotherapy), while INT-0116 did not give pre-operative chemotherapy. We don’t have data demonstrating that combining the two ...
Which regimen is better for gastric adenocarcinoma- neoadjuvant chemotherapy or adjuvant chemoradiation?
There are common criticisms of both the MAGIC and INT-0116 trial results.In the MAGIC trial consisting of preoperative (3 cycles ECF) and postoperative (3 cycles of ECF) vs surgery alone, there was inconsistent preoperative staging.. Lymph node dissections were left to the discretion of the surgeon ...
Should nodal fields be added to post-mastectomy radiation treatment after neo-adjuvant chemotherapy if there is a CR in the nodes?
There is no good study for this clinical situation. NSABP is conducting a trial where pts who have pCR in clinically positive nodes are being randomised to regional RT vs. no regional RT. In practice, I usually treat for patients with pretreatment clinical N2 disease or have inflammatory breast canc...
For rectal cancer with solitary liver metastasis, do you recommend neoadjuvant chemoradiation?
If the patient is being managed with curative intent (i.e. there is a plan for surgical resection of both the rectal and liver tumors), then preoperative pelvic chemoRT is reasonable for the same reasons it's indicated in the non-metastatic setting. This is a scenario where we often entertain short-...