Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are your triggers for BM biopsy in polycythemia vera?
We may do a BM biopsy at diagnosis for pediatric patients, but do not generally do them as part of our diagnostic work-up, especially if JAK2 mutant. However, if there is evidence for myelofibrosis (falling counts) or leukemic transformation, we would do a biopsy.
How do you approach treatment for ovarian carcinosarcoma that has progressed during adjuvant carboplatin, paclitaxel, and bevacizumab following optimal tumor reductive surgery?
Recurrent ovarian carcinosarcoma (OCS) is a difficult clinical scenario with few evidence-based options. Clearly, a need exists for novel therapies, and a frank discussion on treatment goals and expectations is warranted. Ovarian carcinosarcoma (OCS) is a rare histologic subtype of ovarian cancer ac...
In terms of contraception, what do you recommend for patients with a history of hormone receptor-negative compared to hormone receptor-positive breast cancer?
Avoid oral contraceptives. Prefer barrier contraception and IUD.
Do you perform a periodic PET CT to screen for extramedullary disease in patients with MM who are in remission?
This is an excellent question with guidelines and inferences from clinical trials, but admittedly, no randomized data showing that surveillance PETs improve outcomes versus as-needed PETs. To start, here's what NCCN guidelines recommend for patients in surveillance/on maintenance therapy alone: "Who...
Where does Elotuzumab-based combination therapy, specifically EPd, fit in your treatment paradigm for relapsed MM?
The ELOQUENT-2 study evaluated Elotuzumab+Len/Dex vs Len/Dex alone showing improved PFS that was statistically significant and 4-year OS proportion of 50% vs 43% (HR 0.78, 95% CI 0.63-0.96). This required patients essentially be lenalidomide naive in 90% of the study population - something that is v...
Do you offer durvalumab in combination with gemcitabine and cisplatin in patients with metastatic ampullary adenocarcinoma, given the fact that ABC-02 trial included patients with ampullary adenocarcinoma while TOPAZ trial excluded those patients?
Unfortunately we don't have robust contemporary data for ampullary adenocarcinoma. In general I would not apply the TOPAZ-1 study findings to this population.
Do you hold ADT prior to biopsy of possible prostate cancer metastatic disease?
ADT can affect the ability to assign a Gleason score, but I am assuming this is not an issue here. We biopsy new sites of metastatic disease in people on ADT all the time to confirm progression and to get tissue to identify potentially actionable targets. The only time I would deliberately hold ADT ...
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.