Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you still consider durvalumab consolidation after definitive chemoradiation for patients with Stage III NSCLC who are on stable weekly methotrexate dosing for psoriasis/psoriatic arthritis?
I would. Given the (now) long-term follow up with the PACIFIC trial showing an approximately 10% improvement in 5-year survival from 33 to 43% (Spigel et al., ASCO 2021, abstract 8511), I believe the risk of psoriasis flare is acceptable. I would have a discussion ("shared decision") with the patien...
For relapsed/refractory myeloma, how long of a disease-free interval from first autologous transplant do you recommend before considering a second autologous transplant?
This is an excellent question, and I appreciate Dr. @Dr. First Last's choice of "second ASCT" and not "salvage ASCT" - I still catch myself saying the latter, but the wording is as patient-unfriendly as it gets.When considering a second ASCT (whether with repeat collection or with cells saved up fro...
What would be your approach to initial treatment of a patient with standard-risk myeloma unwilling to undergo autologous stem cell transplant, if practicing in a resource-limited setting?
For non-transplant candidates or patients unwilling to have transplant with standard risk MM, these are my 2 choices: RVd: len/velcade/dex: based on the SWOG S077 compared to Rd: Durie et al., PMID 28017406. Dara Rd: Daratumumab/Revlimid/dex: based on the MAIA study compared to Rd: Facon et al., PMI...
How do you approach treatment of recurrent histiocytic sarcoma in a young, healthy patient after surgical resection?
HS is a very rare type of malignant histiocytosis with dismal outcomes for multifocal disease. Given the rarity, there are very little data on the management of this disease, and management approaches are based on anecdotal and small retrospective experiences. For unifocal disease that can be entir...
Would you recommend tamoxifen x 5 years following mastectomy in a male with pure DCIS?
I would not. The risk of developing contralateral breast cancer in a woman with DCIS is about 5% per decade, or 0.5% per year. At this level of risk, chemopreventive tamoxifen is an appropriate consideration. The risk of contralateral breast cancer in a man with DCIS is uncertain, but is almost cert...
How would you approach the treatment of cytopenia related to NK cell LGL leukemia?
You could use filgrastim and erythropoietin but I prefer to treat the underlying leukemia with low dose methotrexate or cytoxan. It may take up to 6 months to see responses to cytotoxic agents and you would need to support the patient during this time with transfusions or growth factors. Thrombocyto...
Based on KEYNOTE-811, would you add pembrolizumab for HER2+ distal esophageal adenocarcinoma with new supraclavicular lymph nodes if treated previously with concurrent chemoradiation and PD-L1 CPS of 3?
There are a few important pieces of information needed to make a good therapeutic decision in this case: Age and comorbidities of the patient, performance status. Duration of progression free interval since finishing Chemo-Rads. What kind of imaging is done to assess extent of disease. Having sai...
For a young male with Stage III intermediate risk NSGCT with active 1 ppd smoking history but normal PFTs and DLCO results, would you still consider use of BEP x 4?
I agree with Dr. @Dr. First Last. However, intermediate risk is between good risk and advanced disease, and in my opinion, despite the NCCN guidelines, I have never seen the logic nor the necessity of treating ALL intermediate patients the same as advanced disease with BEP X 4. Most of my intermedia...
With the recent FDA approval of neoadjuvant chemotherapy and nivolumab for Stage IB-IIIA NSCLC, does the fact that the study used AJCC 7th edition staging impact your patient selection at all since we currently are using 8th edition staging?
No. The regimen is approved for all tumors greater than 4 cm OR node positive, and broad benefit was observed in all clinical categories.
Would you administer postoperative adjuvant atezolizumab or chemotherapy for patients with locally advanced NSCLC and pathological residual disease following neoadjuvant nivolumab/chemotherapy and surgical resection?
This is an excellent question. First, I would encourage all to check out some wonderful thoughts by Dr. @Dr. First Last in two separate questions regarding perioperative NSCLC here and here. There are additional insights in this question as well. As of now, we do not have firm data on what, if any, ...