Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For patients with locally advanced rectal cancer who desire organ preservation and can tolerate fluoropyrimidine but not oxaliplatin, what is the appropriate treatment approach?
For patients with locally advanced rectal cancer who desire organ preservation and cannot tolerate oxaliplatin, the appropriate treatment approach would be neoadjuvant, long-course radiotherapy combined with fluoropyrimidine-based chemotherapy. After neoadjuvant treatment, patients are ev...
How do you manage multiple brain metastases from small cell lung cancer?
In general, I think WBRT is a reasonable treatment for small-cell lung cancer (SCLC) brain metastases. That being said, our institution has considered SRS for select patients depending on a variety of factors as the treatment paradigm for this is evolving. There have been some studies addressing SRS...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
In the case of a patient with untreated chronic hepatitis C, I would offer upfront atezo/bev, as long as hepatic function is appropriate. At our center, hepatitis C treatment is generally not offered to patients with advanced HCC. Interestingly, only 21% of patients treated with atezolizumab/bevaciz...
Do the higher rates of grade 1–2 pulmonary fibrosis with hypofractionated PMRT in CHN HYPOPMRT change how you counsel patients about long-term lung toxicity when choosing between fractionation schedules?
The higher rate of grade 1-2 pulmonary fibrosis with hypofractionated postmastectomy radiotherapy in CHN HYPOPMRT does not change my recommendation. The excess toxicity is confined to grade 1-2 disease—largely radiographic or mildly symptomatic fibrosis. Importantly, the abstract reports grade 1-2 f...
Given the equivocal findings of NRG GI003, in which patients would you select for liver-directed proton therapy in the management of HCC?
Based on the results presented, there is not an indication to routinely recommend proton-based radiation for HCC. There are ongoing efforts to see if there is a subgroup that benefits from protons.
For large HCCs, if the normal tissue complication probability is unacceptably high for a 5-fraction photon SBRT plan but is acceptable for a 5-fraction proton SBRT, would you recommend 5 fractions of protons or 15 fractions of photons?
No, this is not recommended in light of the unexpected finding that patients with tumors over 5 cm had a worse outcome with protons on multivariable analysis. This finding is puzzling, and we will be doing further analysis to understand it.
How do you approach the choice between 3-fx and 5-fx postop SRS for a resected brain metastasis for intermediate cavity volume?
In my practice, I generally use single-fraction SRS for lesions/cavities smaller than 2 cm in maximum dimension or ~4 cc in volume to 18 - 20 Gy, but this is a relatively rare occurrence given the fact that resected brain metastases tend to be larger.For cavities larger than 2 cm (or about 4 cc volu...
Do the 8-year PACE-A results support a claim of equivalent long-term cancer control between SBRT and prostatectomy?
The PACE-A trial is a phase 3 trial that randomized 123 patients with low- and intermediate-risk prostate cancer to a prostatectomy or prostate SBRT (36.25 Gy in 5 fractions) without androgen deprivation therapy (ADT). Overall, 94% had intermediate-risk disease and 84% of prostatectomies were roboti...
How do you select first-line therapy for PD-L1-positive metastatic TNBC?
At this point, we only have mature data on pembro and SG, and this is the regimen I would use.