Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
How would you manage metastatic small cell/neuroendocrine bladder cancer after response to 6 cycles of platinum/etoposide?
I would consider maintenance avelumab in patients with metastatic small cell carcinoma of the bladder achieving stable or responding disease after platinum-etoposide. Notably, the JAVELIN Bladder-100 trial that led to the approval of maintenance avelumab included urothelial carcinoma and not predomi...
Would you provide TDM1 or capecitabine for residual disease in HR negative patients with HER2 positivity based on copy number alone?
It is not clear from the question what is meant by "copy number alone." To be HER2 positive by copy number alone is a copy number equal or greater than 6.0 (unless IHC 0 or 1 + with a ratio also < 2.0, in which case the tumor is HER2 negative). If the copy number is between 4 and 6, but the ratio is...
Do you find data from phase 2 DESTINY-LUNG01 study sufficient to change practice in HER2 mutant NSCLC or is a phase 3 study still needed?
I think that phase 3 data are needed but not in the second-line setting. I think a phase 3 trial in the first-line setting of T-Dxd versus chemo +/- IO is the way to go.Based on DESTINY-Lung01, trastuzumab deruxtecan is more effective than other HER2 targeted strategies overall.
What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?
Educating clinic staff and patients/family members is key. Any reports of worsening respiratory symptoms such as worsening cough or SOB should be carefully worked up and managed. Always check for saturation at clinic visits and (actively) look for interstitial findings at every scan (the patient cou...
How do you interpret efficacy of trastuzumab deruxtecan based on HER2 mutation type and/or level of HER2 overexpression?
In the phase 2 DESTINY-Lung01 study, the majority of the HER2 mutation was at exon 20 and were insertion mutations. There were other rare HER2 alterations such as exon 19 and extracellular domain mutation in exon 8 that also responded to trastuzumab deruxtecan. Some of these patients had their HER2 ...
What is your approach to adjuvant treatment for stage IA small cell carcinoma of the ovary, hypercalcemic type, after fertility sparing surgical staging?
Due to the rarity of small cell carcinoma of the ovary hypercalcemic type (SCCOHT), limited prospective data exists to inform treatment decisions. Like other malignancies in the malignant rhabdoid tumor (MRT) family including renal and extra-renal MRT and atypical teratoid rhabdoid tumors (ATRT), SC...
What is your recommended adjuvant approach to resected NSCLC with both PD-L1>1% and EGFR mutation?
IMpower010 included patients with EGFR mutations, which made up about 10% of the patients enrolled in the trial. In the subgroup analysis of EGFR patients whose tumors expressed PDL1 ≥1%, the HR of 0.57 favored atezolizumab, but had a wide confidence interval (95% CI, 0.26-1.24). Other studies of im...
Would you recommend the addition of chemotherapy in a patient with locally recurrent, unresectable squamous cell carcinoma of the head and neck for whom repeat radiation is planned?
There is no standard of care in the setting of an unresectable, resistant local/regional recurrence after full dose RT and concurrent cisplatin. If the patient has a good PS, is medically fit, and the goal is a salvage cure, I would discuss adding a taxane to the planned RT. In an attempt to overcom...
Would you extrapolate IMPower010 data to offer adjuvant atezolizumab to a patient with N2 PDL1-high (>50%) NSCLC who had been treated with induction chemotherapy followed by definitive R0 resection after partial response?
As outlined by Dr. @Dr. First Last, IMpower010 did not enroll patients who had received neoadjuvant chemotherapy and I fully agree that neoadjuvant chemotherapy + immunotherapy trial would be appealing in patients with N2 disease. Especially, since treatment of these patients is controversial and ch...