Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to locally advanced pancreatic cancer that has not progressed after neoadjuvant chemotherapy +/- chemoradiation but remains unresectable?
NRG GI011 was recently activated across the NCTN and will test ablative radiotherapy in this setting. This is a pragmatic and potentially practice-changing trial. Consider activating it at your center. Here is a nice summary from the PI @Dr. First Lasthttps://www.youtube.com/watch?v=MNsS7pHqZIk.
Which GI cancer patients do you use oral contrast in staging CT scans?
We do not use oral contrast for most of our patients and only offer oral contrast CT scans for patients we are concerned about perforation.
What is your preferred third-line therapy for metastatic colon cancer, RAS-WT, MSS, low TMB, with no targetable alterations?
My preferred treatment in this scenario is trifluridine-tipiracil plus bevacizumab. This is based on the favorable side-effect profile of this regimen (compared to alternatives) and the evidence from the SUNLIGHT trial, which showed that bevacizumab plus trifluridine-tipiracil was superior to triflu...
In a patient with unresectable HCC who developed immune-related colitis with the first dose of tremelimumab/durvalumab, would you consider continuing durvalumab alone after resolution of the colitis with steroid treatment?
I haven’t seen too many TREMI/DURVA colitis cases, but basing experience off of BOT/BAL, which is notorious for the CTLA-4 inhibitor-related BOT-colitis, as well as some patients who have had IPI/NIVO colitis, or any grade ≥3 event in the combination setting, it’d be reasonable to continue the PD1/P...
Would you offer adjuvant therapy to a patient with a high-grade mucinous appendiceal neoplasm that is pT3 pN0 M0, >12 lymph nodes removed with ileocecectomy?
I would.
How long would you continue atezolizumab/bevacizumab in a patient with HCC who is having a prolonged response with stable disease?
Similar to how this was done in the phase 3 trial of atezolizumab/bevacizumab (vs sorafenib), I continue until progression or intolerance. Finn et al., PMID 32402160
In a patient with de novo stage IV breast carcinoma harboring an RB1 Q395* (nonsense) mutation, would treatment with a CDK4/6 inhibitor be appropriate, or should it be avoided due to likely resistance?
Thank you for bringing up this question. As I outlined below, it makes sense based on the evidence available that CDK4/6 inhibitors are less effective or ineffective in patients with tumors harboring Rb LOF mutations. There is, however, little guidance from clinical trials or guidelines to lead us t...
How are you deciding between T-DXd/pertuzumab and THP> HP/tucatinib in patients with metastatic HER2+ breast cancer?
I am reserving HP/tucatinib to the maintenance setting (after 1L THP, as was studied in HER2CLIMB-05, but also will plan to offer it as maintenance after 1L T-DXd/P in patients who experience cumulative toxicity on T-DXd/P and need to stop). I would tend to offer HP/tucatinib maintenance to those wi...
What neoadjuvant strategies do you utilize for initially unresectable biliary tract cancer?
Great question. While there is not prospective data, I tend to use the triplet chemo regimen of gem/cis/nab-paclitaxel based on the 20% conversion rate seen in this phase 2 study. There is an ongoing neoadjuvant study in IHCC that is investigating the triplet, but this is only open at select centers...
Can an AYA patient with newly diagnosed AML safely sperm bank after starting cytoreduction with hydroxyurea or cytarabine?
Thanks for the question. Unfortunately, there is not a lot of data available to answer this question with certainty. Because of that, I err on the side of saying that this should not be done. The concern lies with the possible impact on the sperm DNA, and the subsequent effect that might have on a p...