Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What, if any, adjuvant therapy would you offer a high risk (based on size, location, mitotic rate) GIST patient who is wild type or PDGFRA D842V mutated?
Unfortunately, there is no evidence that would support the use of postop adjuvant therapy for WT (regardless of the subtype) or PDGFRA D842V mutant high-risk GIST. The SOC would be close observation and consider mutation-appropriate options with measurable/evaluable disease.
How would you manage a patient with PSA relapse 10 years after salvage radiotherapy with PSA doubling time<6 months?
Depending on PSA, would image with PSMA PET - typically, will do around PSA 0.5 or higher (given most insurances will not cover multiple PETs in a short timespan, and detection rates of ~50% at PSA 0.5-1 per CONDOR). If no targetable (by XRT) disease on that, would discuss ADT given increased risk o...
Would you consider adjuvant immune checkpoint inhibitor therapy for non-small cell lung cancer patients with residual disease after neoadjuvant chemoradiation and surgical resection?
Prior radiation was an exclusion criteria for adjuvant atezolizumab in IMpower010. Also, neoadjuvant chemotherapy was not permitted and patients only received 4 cycles of adjuvant cisplatin based chemotherapy prior to atezolizumab. So this would be outside the scope of the trial. That being said, I ...
Are there known biomarkers predictive of IRAEs?
While there are no FDA-approved biomarkers predictive of iAEs, there is a growing body of preclinic and retrospective research trying to address this important question. Eosinophilia may be a potentially useful biomarker and this is supported by several retrospective studies 1,2. It is intriguing th...
Would you give checkpoint inhibitor therapy to a cancer patient with known dermatomyositis given the association of checkpoint inhibitor associated myocarditis, myasthenia gravis, and myositis?
I think the dermatomyositis could be more paraneoplastic that would actually benefit from controlling the cancer with ICI. I would give the treatment but I would carefully follow-up the patient for any irAEs. I will also document the rheumatological assessment, CPK, and myositis panel before startin...
How do you discern whether elevated liver enzymes are from immunotherapy versus chemotherapy when a patient is on combination chemo/immunotherapy?
There is no consensus on the best method for distinguishing the cause of elevated liver enzymes in patients being treated with ICPi's when combined with various chemotherapies. Important considerations include time of onset, severity, and presence of hepatobiliary metastases. Hepatotoxicity from ICP...
Which molecular biomarkers do you favor to risk stratify patients (without CV risk factors) before and after undergoing treatment with cardiotoxic cancer treatments?
In general, troponin, NTproBNP or BNP, and lipid panel are the main biomarkers I use for CV risk stratification prior to cancer therapy. Baseline troponin and NTproBNP are primarily useful for cancer therapies that may cause cardiomyopathy or myocarditis (i.e. anthracyclines, anti-HER2 therapies, VE...
Would you consider starting an ACE inhibitor on a patient without CVD or heart failure prior to initiation of anthracyclines to reduce the overall risk of myocardial toxicity?
Even though the patient does not have CVD or heart failure history, there are still factors to consider if they are at higher risk for anthracycline cardiac toxicity: Lower EF at baseline, significant valvular heart disease, prehypertension/hypertension, diabetes, obesity, advanced age, any subclini...
Among asymptomatic patients with structurally normal TTE undergoing treatment with anthracyclines or alkylating agents that develop mildly elevated BNP and/or troponin levels, would you consider referring them for cardiac MRI to evaluate for subclinical cardiotoxicity?
If TTE images are adequate and the echo is entirely normal, but BNP and/or troponin levels are mildly elevated after anthracyclines or alkylating agents, differential diagnosis includes HFPEF, ischemia, or subclinical cardiotoxicity. If Echo shows unexplained significant LVH, CMR is reasonable to ru...
Is cross reactivity low enough to try cisplatin as an alternative for patients who experience hypersensitivity reaction to carboplatin?
A couple of preparatory comments. First, there is a reasonable review recently published about platinum sensitivity and management questions related to this (Makrilia et al., PMID 20886011). The second comment is that platinum sensitivity reactions can be quite severe, and are relatively rare with <...