Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What tumor-related factors help in deciding between BRAF/MEKi vs ICI in stage IV BRAF mutant melanoma patients?
Any patient who has a contraindication to ICI (autoimmune disease, transplant, etc...), I start with BRAF inhibitors, unless the patient is eligible for a clinical trial. Otherwise, I start with ICI, given the latest results of ECOG EA6134. Whether I choose combo with ipi and single agent PD1 inhibi...
What is your preferred first line treatment approach for a patient with PDL-1 high (>50%) NSCLC presenting with CNS mets?
The treatment decision and sequencing in patients with brain metastasis from non-oligometastatic NSCLC with high PD-L1 expression and no traditional actionable genomic alterations depend on size and location of brain mets as well as associated symptoms.Based on data from several prospective and retr...
Would OncotypeDx impact your decision to provide adjuvant chemotherapy for node-negative HR+ breast cancer with dermis or chest wall involvement?
While I'm tempted to use Oncotype or other genomic assays to omit chemotherapy as much as possible (and TBH, Oncotype may be more of a prognostic than predictive assay except at the very upper range - see Mitch Dowsett's examination of these assays, Buus et al., PMID 33108242), the prospective trial...
Would you hold osimertinib in a patient with a STEMI, and for how long?
Compared with other EGFR TKIs, osimertinib seems to have a higher risk for cardiac events including decreased LVEF and prolongation of QTc. In an interesting analysis utilizing the FDA Adverse Events Reporting System (FAERS), investigators found that, when compared with all drugs reported in this da...
Do you send OncotypeDx testing in breast cancers with mucinous histology?
I don't send Oncotype in pure mucinous tumors routinely. NCCN doesn't recommend adjuvant chemotherapy for node negative favorable histology tumors due to their good prognosis. Retrospective studies (Turashvilli et al., PMID 28702894, Wang et al., PMID 30619463) show the majority score low to interme...
Would you offer adjuvant chemotherapy, osimertinib, or both to a patient with Stage IB EGFR mutated lung adenocarcinoma found in the lung explant pathology after bilateral lung transplant?
This is such a rare and individualized case that there will likely be no correct answer. My understanding of the facts is that stage IB lung adenocarcinoma was found on the removed explanted lung after a lung transplant. The question posed is what is the role of adjuvant systemic therapy? Ignoring t...
How do you differentiate between JAK2 positive ET and PV when peripheral blood shows erythrocytosis and thrombocytosis?
The answer to this question is very simple. Before the discovery of erythropoietin and accurate assays for it, and before the discovery of JAK2 driver mutations, the diagnosis of polycythemia vera was clinically-based. The Polycythemia Vera Study Group (PVSG) did an extensive epidemiologic study and...
Would you consider dual anti-HER2 therapy for a perimenopausal woman found to have multifocal pT1mic pN1mic HER2+ HR- breast cancer following a bilateral mastectomy for DCIS?
The optimal treatment for DCIS with microinvasion DCISm is not fully established. There is a nice analysis and discussion from Si et al., PMID 33344258 outlining the factors for worse outcomes. Her multifocality, ER-HER2+ status, and most importantly, nodal involvement increases her risk compared to...
Would you give chemotherapy to a fit patient with myxoid liposarcoma of the knee that is resectable with adverse functional outcomes who will be undergoing neoadjuvant radiation and resection?
I give ifosfamide to people with myxoid/round cell liposarcoma.In general, I do not give adjuvant chemotherapy to adult-type soft tissue sarcomas because of the phase 3 EORTC studies showing that it did not improve survival.Le Cesne et al., PMID 25294887 But I do give ifosfamide to people with myxoi...
Do you give an etoposide-based regimen/more aggressive therapy for lymphoma-associated HLH, such as da-EPOCH-R over R-CHOP?
The general approach to treat the secondary lymphoma-associated HLH (LA-HLH) is to treat the underlying lymphoma- it works better in B cell lymphoma. Etoposide is probably the only agent consistently that has been shown (in several studies- mostly retrospective) to make a difference in the resolutio...