Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Which FGFR inhibitor do you prefer for patients with cholangiocarcinoma and an FGFR2 gene rearrangement?
There are 2 FGFR inhibitors which are currently FDA approved (infigratinib and pemigatinib) and multiple other FGFR inhibitors in development. Futibatinib and derazantinib may get approved soon in the future as well. Looking at data and considering clinical trial differences, I am not sure there is ...
How would you manage a resectable satellite/in-transit melanoma recurrence that developed during adjuvant immunotherapy?
I'm not sure if there is one correct answer in this situation. Could consider intra-lesional TVEC therapy - particularly if the melanoma is BRAF wild type. If this is the case, can fold in an anti-PD-1 antibody in conjunction with intra-lesional TVEC. While this combination has failed in phase III s...
In stage II/III node positive patients with driver mutations positive NSCLC who are not surgical candidates and are unlikely to tolerate concurrent chemotherapy and radiation, would you consider radiation alone, TKI alone, or would you ever consider TKI + RT?
I am not aware of any data in this regard. Recently, we treated a 78-year-old female patient with MET exon 14 skipping mutation NSCLC with bilateral mediastinal and bilateral supraclavicular lymph node involvement on radiology scans. We were concerned about her ability to tolerate concurrent chemoth...
How do you approach a patient with lower risk stage III colon cancer who is unable to tolerate the planned 3 months of oxaliplatin-based therapy due to neuropathy?
For a stage III patient, I would favor dropping oxaliplatin and just continuing 5FU/leucovorin for the final 3 months (total of 6 mo of treatment). As this is early to see this degree of neuropathy, consider screening for other contributing causes, such as B12 deficiency or diabetes. If this patient...
Does the presence of an ATM mutation in advanced stage ovarian cancer influence the decision to use Bev vs PARP inhibitor for maintenance?
I would not use the presence of an ATM mutation alone to inform decisions between bevacizumab vs PARPi maintenance. There are several options for maintenance in the 1L setting, and these include single agent PARPi, PARPi + bevacizumab, or bevacizumab monotherapy. Using data from the PAOLA-1 trial, i...
What induction combination(s) would be appropriate for newly diagnosed standard cytogenetic risk multiple myeloma who have a transplanted kidney?
This is a tough question! On one hand, the risk of allograft rejection with IMiDs is a real concern. On the other hand, one must consider that the evidence for this is limited to case reports/series (ex Walavalkar et al., PMID 29661456; Lum et al., PMID 28189378; Nguyen et al., Blood (2019) 134 (Sup...
How would you manage an asymptomatic elderly frail patient with newly diagnosed mantle cell lymphoma with TP53 mutation?
While p53 mutations are known to impact clinical outcome after administration of cytotoxic chemotherapy in frontline MCL (Eskelund et al., PMID 29794145, Elhassadi E et al. Presented at: 2019 European Hematology Association Congress; June 13-16, 2019; Amsterdam, The Netherlands. Abstract PF493, Ferr...
Would you continue IO monotherapy in a patient with metastatic RCC started on first line IO-TKI combination but with poor tolerance to TKI?
Yes, definitely assuming no limiting irAEs. There is clear activity to IO monotherapy in mRCC as evidenced by KEYNOTE 427 and other datasets. Combination therapy is superior, however, so dose interruption/modification of the TKI should be attempted before discontinuing permanently.
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...