Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are there situations in which neoadjuvant chemoimmunotherapy + surgery would be preferred over chemoradiation + consolidative immunotherapy for stage III lung cancer?
We are good at controlling tumors of one billion cells (1 cm size), less so for one trillion (10 cm). From a radiobiology point of view, when I see a resectable T4 tumor due to size over 7 cm, I usually ask my surgeons if they can please take it out. You suddenly get rid of half a trillion tumor cel...
How would you approach therapy for a patient with smoldering multiple myeloma whose light chain ratio has increased to greater than 100 over several years in the absence of any other myeloma-defining events?
I struggle with this as well, but the serum free light chain ratio (SFLC-R) at 100 is not magical for a patient that you've been following. An SFLC-R>100 is predictive of an increased risk to develop CRAB criteria of 60-90% w/in 2 years. This prediction is refined by measuring 24hr UPEP using a bar ...
Should IMPower010 results be extrapolated to superior sulcus tumors treated with chemoradiation and surgery?
No. Patients with superior sulcus NSCLC, for whom the standard of care is preoperative chemotherapy and radiation therapy followed by surgical resection, would all have been ineligible for IMpower010, which used chemotherapy +/- Atezolizumab in the purely adjuvant therapy setting. Therefore, the res...
What are your recommendations for management of patients with familial polycythemia due to EPOR mutation during pregnancy?
This is not a question that has a definitive answer since I know of no reports dealing directly with this uncommon situation and I have never treated such a patient. I have, however, successfully treated many pregnant vera patients, who have a constitutively-active erythropoietin receptor (EPOR) due...
How do you treat metastatic, wild-type GIST?
Majority of these are SDH deficient. For these patients, if a clinical trial is available, that would be preferable. From a SOC standpoint, EU investigators have data on Regorafenib. For the rare WT GIST with B-raf mutation or NTRK fusion, appropriate targeted therapy would be indicated.
What is your approach to CNS surveillance in resected superior sulcus tumors given high rates of intracranial metastasis in this population?
Despite the quantum improvement in complete surgical resection, pathologic complete remission, and overall survival rates in S9416/INT-0160 (the trial that established trimodality chemoradiation followed by surgery as the standard of care for superior sulcus NSCLC almost 2 decades ago), distant recu...
What is your preferred adjuvant therapy for a patient with triple negative breast cancer and has a BRCA germline mutation who had minimal to no response to neoadjuvant chemotherapy?
The vast majority of OlympiA patients had both anthracycline and taxane therapy. Very few had less than 6 cycles of chemo or only one of the two agents. For this case, I would try to do 4 cycles of dose dense anthracycline treatments then adjuvant olaparib for 1 year.
For patients receiving outpatient venetoclax/azacitidine who develop profound neutropenia with ANC <200, do you admit for monitoring during the nadir in the absence of fever?
I don't think I would admit these patients. My recommendation would be to monitor temperature daily or feel febrile and let the clinic know if they have any symptoms of localizing infection. The NCCN and IDSA guidelines talk that only neutropenic patients with fever, even amongst those who have the ...
Would you consider a PARP inhibitor in the treatment of a PARP inhibitor naïve platinum resistant recurrent ovarian cancer with LOH/HRD?
These are challenging scenarios and with increasing PARP use in the upfront setting, especially (likely) in the LOH/HRD patients I suspect this clinical scenario may become less frequent in the future. For now, it's appealing to suggest that LOH/HRD scores as a biomarker can be examined in a vacuum ...
Would you consider adjuvant chemotherapy in the management of retroperitoneal leiomyoscarcoma who did not respond to neoadjuvant doxorubicin/dacarbazine?
If pre op ADIC failed and the RP LMS is completely resected with NED, I would just pursue close observation.