Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider radical prostatectomy for a young male with unfavorable intermediate risk cT3a prostate cancer and PSMA PET concerning for regional lymph nodes involvement but negative conventional imaging?
I would approach this scenario by considering two main issues. The first issue is what the probability of the patient truly having pN+ disease based on cN+ findings on advanced imaging. There have recently been two trials published from the Netherlands, PEPPER (using 68¸Ga-PSMA-11) and SALT (using 1...
How do you advise a patient with VTE on indefinite anticoagulants regarding the Ad26.COV2.S Johnson & Johnson/Janssen COVID vaccine?
The thrombotic events seen with the Ad26.COV2.S vaccine do not appear to be associated with a prior history of clotting events. It seems to be a different entity, similar to heparin induced thrombocytopenia, with clinical presentation of thrombosis and thrombocytopenia. Muir et al., PMID 33852795The...
Can adjuvant nivolumab for bladder CA as per Checkmate 274 be extrapolated for the concurrent chemoRT bladder preservation setting?
Great question. Short answer is no. Different scenario and very hard to extrapolate from the adjuvant post radical cystectomy setting. We need dedicated bladder preservation trials, e.g. S1806 and Keynote992. Recommend to accrue in those 2 large phase III trials for patients who opt for bladder pres...
In a patient with localized TNBC, how would you decide in whom to perform breast MRI prior to starting neoadjuvant systemic therapy?
In general, obtaining breast MRI prior to neoadjuvant is mainly based on the type of surgery that is planned. If lumpectomy is planned, then breast MRI should be obtained prior to neoadjuvant chemo and after neoadjuvant chemo but before surgery. If mastectomy is planned, then breast MRI does not add...
In patients with RET-fusion positive NSCLC with symptomatic brain metastases, would you consider starting selpercatinib/pralsetinib upfront or would you proceed with whole brain radiation with TKI to follow?
In general, my favored approach for a patient with asymptomatic brain metastasis (and nothing scary like big edema, midline shift, bleeding, etc) is brain-penetrating TKI, if available. This applies to EGFR (osi), ALK (alectinib), and RET (I use selpercatinib). Happily, these patients live longer. W...
What recommendations are you giving when patients ask about the best 'cancer diet' to be on?
I counsel patients that there is no definitive data on "cancer fighting foods." What we do know is that nutrition is important for patients undergoing active cancer treatment and involving nutrition can be helpful - and is in fact, a component of many geriatric assessment intervention trials. Resear...
What is your approach to immunotherapy-related pancreatitis?
Depending on the severity of the ICI-associated pancreatitis, I will start patients on prednisone 0.5 mg/kg/day - 1 mg/kg/day. Once lipase levels decrease and approach normal levels, I will start tapering at generally around 10 mg weekly with a total taper time that is typically close to 6 weeks. If...
Would you give adjuvant immunotherapy after nephrectomy?
The KN-564 will certainly change the landscape of adjuvant RCC. Prior studies had either been negative, or have been positive (sunitinib in S-TRAC) but with toxicity that has precluded widespread use. The OS data from KN-564 is too immature to interpret, in my opinion, so the debate of whether to tr...
Are there any data for second line nivolumab-ipilimumab in patients with metastatic NSCLC treated with either single agent pembrolizumab or chemotherapy + ICI as first line therapy?
Resistance to PD-(L)1 inhibitor based first line therapy and choice of subsequent treatment for patients with advanced NSCLC is an ongoing challenge. While addition of CTLA-4 inhibitor to PD-1 inhibitor has shown additive anti-tumor activity via complementary mechanisms of action, it is currently un...
How will you decide among the options of either carbo/gem>avelumab or checkpoint monotherapy for cisplatin-ineligible PD-L1 expressing urothelial carcinoma?
The KEYNOTE 052 data as well as other datasets support the idea that there are clearly a subset of previously-untreated cisplatin-ineligible metastatic urothelial cancer patients who receive benefit from front-line immunomonotherapy and can be treated with this approach. Importantly, responding pati...