Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients with metastatic RCC who have had a complete response to pembrolizumab and axitinib and undergone a nephrectomy, how long would you continue therapy post-operatively?
This is a great question and increasingly relevant. The larger question is about duration of IO-based therapy in general, especially when patients are at maximal response (CR or deep and stable PRs). The honest answer is that nobody knows. My sense is that the decision is based on pt preference and ...
In a patient with intermediate risk metastatic RCC with high thrombotic tumor burden in the IVC extending to the right atrium, is there any clinical or biologic rationale to guide choice of therapy between axitinib/pembrolizumab vs nivolumab/ipilimumab?
The short answer is no. IVC thrombi have never been reliably responsive to either IO or VEGF-targeted approaches. The first question may be if there is a role for debulking nephrectomy in this pt. If there is only 1 IMDC risk factor and this represents the majority of tumor burden, I still believe n...
How would you manage a CML patient with a T315I mutation that developed severe abdominal pain requiring hospitalization after starting ponatinib 45 mg?
If abdominal pain started after ponatinib was started it is important to rule out complications related to the drug. Thrombosis was ruled out, which is important as ponatinib can cause venous and arterial thrombosis. It is also important to rule out pancreatitis. If no other etiology is found and th...
When treating DLBCL with induction therapy with R-CHOP, if after 2 cycles, you have a mixed response on PET, would you consider that treatment failure or would you continue R-CHOP?
First, it is not routine practice to evaluate response to RCHOP radiographically after 2 cycles of treatment for DLBCL. If there were clinical concern that the patient were not responding, and imaging was performed with a mixed response - both frankly progressive disease and responding disease - the...
How would you approach a patient with gBRCA mutated, ER+,HER2- metastatic breast cancer with brain mets refractory to WBRT and chemotherapy?
There are several options. I would consider a PARP inhibitor, as there is likely activity in this setting as these small molecules likely cross the blood brain barrier. There is also activity (although modest) of abemaciclib as well in this setting. We also should remember that anti hormonal agents ...
How do you deal with worsening tinnitus in patients on concurrent chemoradiation with weekly cisplatin for head and neck cancer?
Based on data from three studies at our institution whereby we interchanged Carboplatin when cisplatin toxicity was induced, I would substitute weekly Carboplatin (AUC 2) IV weekly with the remaining RT.
When considering adjuvant chemotherapy for resected lung cancer, do you treat rarer histologic patterns such as acinar or lepidic the same as you would a more typical NSCLC?
Quick answer:Lepidic histology can affect the decision for adjuvant therapy.Acinar histology does not affect the decision for adjuvant therapy.Rationale:Lepidic is the AIS component in minimally invasive or invasive adenocarcinomas.Based on Travis', JTO 2016, recommendation not to use the noninvasiv...
How would you approach adjuvant chemotherapy and radiation options in a patient with locally advanced TNBC and Diamond-Blackfan Anemia s/p lumpectomy?
This is one of the many situations for which there is no good published data. In this circumstance, decisions need to be made based on weighing the risks and benefits and considering the patient's values and philosophies. This patient has about a 30% chance of dying of metastatic breast cancer (canc...
How do you treat unresectable, combined hepatocellular/cholangiocarcinoma?
I have historically treated unresectable combined HCC/CCA (CHC) as I have treated unresectable intrahepatic cholangiocarcinomas (IHCCA). I perform Comprehensive Genomic profiling (CGP) upfront in these patients to investigate the presence of actionable genomic targets. If bulky extrahepatic disease ...
How do you counsel patients on the neurocognitive effects of whole brain radiation therapy?
This answer was co-authored with @Dr. First LastThank you for the opportunity to address this important and increasingly complex question. Part of the complexity inherent to this question revolves around the rapidly evolving advances that our field has made in delivering safer brain metastasis treat...