Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you add durvalumab to gem+cis in a patient with recurrent cholangiocarcinoma after liver transplant?
I would not offer gemcitabine/cisplatin plus durvalumab to a patient with recurrent cholangiocarcinoma after a liver transplant. The added clinical benefit of durvalumab is modest, and the risk of a life threatening liver transplant rejection is high.
Would you consider PD-L1 score when deciding whether to incorporate durvalumab in first-line metastatic biliary cancer?
There are no biomarkers that I currently recommend to select patients for durvalumab in first-line metastatic biliary cancer. In subgroup analysis, there appears to be benefit to durvalumab in first-line metastatic biliary tract cancer regardless of PDL1 expression. Therefore, I would not consider P...
What is your approach in a fit patient, advanced stage, bulky classical Hodgkin lymphoma who has decreased disease burden in areas but a persistent, hypermetabolic (Deauville 5) anterior mediastinal mass following two cycles of AAVD?
Biopsy!If persistent HL:I know it is only phase II data, but I've been impressed with the ORR and personal experience with pembro-GVD: Moskowitz et al., PMID 34170745.I hate radiating the chest, but one could argue that option as well.
How would you approach a young patient with stage I follicular lymphoma of the mesenteric lymph nodes?
This is an excellent question that is often discussed in guideline panel meetings- with a fair amount of disagreement among parties. As radiation therapy leads to long-term disease control in ~50% of patients with stage I FL (and is not cured with either chemotherapy or immunotherapy), my preference...
What are your treatment options for HER2 over-expressing metastatic breast cancer in a patient whose LVEF decreased to <50% from normal baseline on HER2-directed therapy and EF fails to improve after holding therapy for 2 months?
The decision for stopping HER2 therapy for cardiomyopathy should be weighed against the risk of their metastatic disease progressing on suboptimal therapy. With closer monitoring and help from a cardiologist to optimize medical management, I have been able to continue effective anti-HER2 therapy in ...
How would you treat a locally-recurrent extraosseous (pulmonary) Ewing sarcoma?
It is possible to re-challenge the patient with the same regimen. Assuming EF and BNP are normal and can be followed, bolus Doxorubicin with Dexrazoxane would allow safe administration of additional doxorubicin. The alternative is to use high-dose Ifosfamide (14 g/m2/cycle). In the event of a good v...
Would you consider SBRT for node negative small cell carcinoma of the prostate?
There are no prospective data to guide the use of RT in the management of small cell carcinoma of the prostate. Retrospective data would suggest possible benefit at least in terms of control of disease in the prostate with the addition of local RT to systemic chemotherapy (see Oke et al., PMID 33824...
Do you ever offer scalp cooling therapy to metastatic breast cancer patients wishing to avoid alopecia?
I routinely offer scalp cooling to such patients. I do acknowledge to patients that we do not have evidence to support scalp cooling in the metastatic setting, that the best evidence to support its efficacy is with taxane-based regimens, and that we really cannot be sure how or if scalp cooling will...
Would an STK11 mutation influence your choice of single vs combination immunotherapy in a patient with MSI-H metastatic CRC?
The presence of an STK11 mutation would not affect my decision to offer immunotherapy for an MSI-high (dMMR) colorectal cancer patient. There is mixed literature about if this might portend a better response to IO treatment (Kwon et al., PMID 32284250.) One should note that with a KRAS mutation in l...
How does avidity on DOTATATE PET impact your choice of whether to start somatostatin analogues in metastatic neuroendocrine tumors?
A negative DOTATATE scan is predictive for a lack of response to SSA therapy including Lutathera so I would not use octreotide or lanreotide for this patient and I would choose something else for treatment. (See for example Lee et al., PMID 32886441)