Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
Would you offer radiation therapy for stage IV pancreatic adenocarcinoma with liver metastases after 12 cycles of FOLFIRINOX and maintenance capecitabine, now with locally progressive disease at the pancreatic primary and rising CA 19-9?
Although not stated in the question, I assume this is a situation in which the liver metastases appear to be responding to chemotherapy with a radiographic partial response or stable disease. If the patient were progressing in both the liver and the pancreas, the next step in management would most l...
Would you offer tarlatamab to patients with metastatic EGFR+ NSCLC that transformed into SCLC?
Yes, in fact, we recently collaborated on a multi-institutional report of a small cohort of such patients and have tried it a few additional times since then for patients with EGFR (or ALK) transformed into SCLC. We have seen a few exceptional responders, suggesting there's a potential role for it, ...
Is DLL3 expression necessary for tarlatamab efficacy in small cell lung cancer?
Yes- tarlatamab is a bispecific T-cell engager targeting DLL3, and thus, DLL3 expression is needed. Given the widespread expression in SCLC in approximately 90% of cases, testing for DLL3 expression prior to administering drug therapy is not required.
Would you continue tarlatamab in CNS-only progression of small cell cancer if there is no systemic disease?
I would absolutely continue tarlatamab in this scenario. While there is evidence of at least some activity of tarlatamab in the CNS (e.g., Zhang et al., PMID 40126456), the effect can be transient, suggesting that intra- and extracranial discrepancy is possible/probable. I would handle isolated, oli...
Would you consider upfront immunotherapy in a patient with MSI strongly positive locally advanced adenocarcinoma of the anus versus standard of care?
Great question. For anal and rectal cancers, histology generally supersedes location in determining treatment paradigm, so an anal adenocarcinoma would be treated like a rectal adenocarcinoma (you might consider anal canal involvement T4 staging).Standards of care for MSI-H locally advanced rectal a...
In a patient with borderline resectable pancreatic adenocarcinoma s/p 10 cycles FOLFOX and aborted Whipple due to locally advanced disease, do you recommend dose escalation beyond 54 Gy?
Yes, there is no contraindication to giving an ablative dose after exploration. 54 Gray is a palliative dose, which has not improved overall survival based on the LAP07 trial. While it's fair to say that we do not know the definition of definitive or ablative in LAPC, we have published OS results ve...
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
Would you add whole-pelvis radiation as MDT (metastasis-directed therapy) in a patient with 1 pelvic node and 2 osseous metastatic sites for castrate-resistant prostate cancer?
This patient would not fit the PEACE V-STORM eligibility criteria, since the trial excluded patients with distant metastases and did not include patients who were castrate resistant, so I do not think you can extrapolate the results to this patient. One could argue that what you propose to do (SBRT ...
How do you treat metastatic bladder cancer with extensive squamous differentiation in a cisplatin-ineligible patient?
The impetus for the question is presumably the impact of squamous differentiation on what has become the standard for metastatic urothelial cancer, namely enfortumab vedotin combined with pembrolizumab. Trials leading to the approval in the metastatic space as well as the perioperative space all req...