Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with mild CKD, how do you decide between zoledronic acid and denosumab for bone protection in patients with multiple myeloma?
In this scenario, I prefer zoledronic acid every 3 months with renally adjusted dose. In my experience, the risk of hypocalcemia seems higher with denosumab. Calcium/vitamin D supplementation would be important as well. The every 3 month dosing is an advantage over denosumab, which would have to be ...
How do you approach adjuvant comprehensive breast or chest wall RT for locally advanced breast cancer on a CDK 4/6 inhibitor?
Prospective data in this setting is limited. Retrospective and preclinical data with palliative RT and CDK 4/6 inhibitors have shown mixed results, with some showing skin and lung toxicities and others not. Adjuvant trials allowed concomitant use, but have not reported separately. My bias for PMRT i...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
Do you routinely obtain CPS assay to assess candidacy for chemoimmunotherapy in newly diagnosed metastatic esophageal/GEJ/gastric adenocarcinoma?
I am still apt to assess tumor PD-L1 CPS to help inform long-term benefit from first-line chemoimmunotherapy in a patient with metastatic disease. Intrapatient, interlesional heterogeneity for PD-L1 CPS has also been recognized in the literature corresponding to discordance in levels of PD-L1 CPS po...
In the modern era, what is the role of beta-emitting bone-targeted radiopharmaceutical therapy?
Since the approval of Radium-223 dichloride (Xofigo), I have been using it as the preferred radiopharmaceutical for patients with mCRPC. While use of Samarium-153 and Strontium-89 improves pain control, Radium-223 is an alpha-emitter and is the only FDA approved radiopharmaceutical that has been sho...
Would you recommend nivo/ipi instead of chemotherapy/nivo or chemotherapy alone in advanced squamous esophageal cancer based on Checkmate 648?
How would you approach a patient whose stage II TNBC tumor is visibly progressing on the KN-522 neoadjuvant regimen?
Yes, in a patient whose TNBC is visibly progressing on neoadjuvant chemotherapy, I would change course by either changing regimen or proceeding with local management. The CR rate to the KEYNOTE 522 regimen is impressive (64.8% with pembo vs 51.2% without pembro; Schmid et al., PMID 32101663), but th...
What adjuvant therapy would you offer a TNBC patient with residual disease after receiving the neoadjuvant KEYNOTE-522 regimen?
Safety is pembro and cape was provided in phase I trials. Risk and benefit weighing is important when discussing with patients.
Would you change treatment in a patient with metastatic CRPC on PARP inhibitor with rising PSA but negative Axumin PET scan?
Short Answer: No Medium Answer: The surrogacy of PSA as an intermediate endpoint in both localized prostate cancer and metastatic prostate cancer has been problematic. Multiple variations have been explored and tested including PSA doubling time (PSADT), PSA nadir, absolute PSA level, etc. None have...
What are your considerations for choice of immunotherapy agent with patients with metastatic pMMR HER2- esophageal/GEJ/gastric adenocarcinoma with CPS >=10?
I alluded to this earlier. Although both CheckMate 649 and KEYNOTE 590 included esophageal cancer, there were caveats. Specifically, in CheckMate 649, there were relatively few patients with esophageal adenocarcinoma. The positive results of CM-649 were clearly driven by gastric adenocarcinoma, part...