Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are some preferred steroid sparing regimens for untreated multiple myeloma patients who have type 1 diabetes mellitus?
The amount of dexamethasone used in current regimens is less than historical regimens of 40 mg daily x 4 days, etc. based on an ECOG trial comparing 40 mg weekly to the older standard (both in combination with Revlimid) https://www.ncbi.nlm.nih.gov/pubmed/19853510. Nevertheless, the amount is still ...
How do you manage non-mucinous metastatic appendiceal adenocarcinoma?
The treatment algorithm for advanced, non-mucinous appendiceal adenocarcinoma is essentially identical to the algorithm for advanced colon adenocarcinoma (including the selective use of metastasectomy to render patients disease-free).
How will you decide between mFOLFIRINOX vs gemcitabine+capecitabine for resected pancreatic cancer patients?
The results of the PRODIGE-24 trial are among the most significant of the last quarter century in terms of their impact on the treatment of patients with pancreatic adenocarcinoma. The administration of mFOLFIRINOX resulted in almost a doubling of 3 yr DFS (the primary endpoint) and also extended th...
Is there any benefit to adding bevacizumab to chemo-immunotherapy in metastatic NSCLC?
In the ITT population of the Impower 150 trial the median OS was 19.2 mo on arm B (Atezo + chemo + bev) and 14.7 mo on arm C (chemo + bev) with a Significant HR of 0.78 but the mOS in arm A (atezo + chemo) was 19.4 mo with no planned comparison to arm B but seems not to be significant. So the presen...
Would you try abemaciclib in a woman on fulvestrant and palbociclib with good systemic control but progression in the brain?
I believe this is a reasonable option as treatment of Brain metastasis remains challenging despite advances in the management of metastatic HR + breast cancer. Abemaciclib, currently approved for the treatment of HR+ metastatic breast cancer (MBC), has been shown preclinically to cross the blood-bra...
How would you approach locally advanced bladder cancer in a patient on hemodialysis?
It depends on "locally advanced" setting; resectable or unresectable tumor?If resectable and not metastatic may consider radical cystectomy and LN dissection in good surgical candidates; however bladder preservation approach can be considered in well selected patients, e.g. small unifocal tumors wit...
Would you consider first line therapy with PD-1 inhibitors (+/- CTLA4) for patients with metastatic NSCLC with high tumor mutational burden despite negative PD-L1?
I would consider giving a patient with metastatic NSCLC and a high tumor mutational burden despite negative PD-L1 treatment with Nivolumab plus Ipilumumab. I would also consider giving the same patient chemotherapy plus a checkpoint inhibitor alone!The optimal treatment for this patient population i...
What is your strategy for assessment of mutations from a liquid biopsy in metastatic breast cancer that has progressed on multiple therapies?
The use of liquid biopsies in patients with metastatic breast cancer who have progressed on multiple therapies is primarily useful for patients eligible and interested in clinical trials in order to prioritize or qualify patients for targeted therapies. Concordance with results from tissue based tes...
How do you time same-day chemotherapy and radiation for patients undergoing concurrent chemoRT?
A great question. It is similar to recipes for pasta sauce - with rare exception no matter how you make it, it's usually good. There are retrospective data which suggest that capecitabine is most effective one hour prior to RT. That is the ideal sequence. However, since it is prescribed q12 hours it...
How do you approach treating a patient with IgM-AL amyloidosis?
Good question. As pointed out, about 5% of lymphomas have a diagnosis of lymphoplasmacytic lymphoma (aka Waldenstroms) instead of a plasma cell dyscrasia. Small burdens of LPL can be difficult to detect unless specific testing is done (e.g., flow for clonal B cells) and intraclonal differentiation (...