Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you initially treat patients with cN3 cM0 esophageal cancer?
This is an extremely heterogenous group and requires expert multidisciplinary review to generate an individualized plan. In fact, we discussed several patients with N3 disease -- very extensive but technically locoregional lymphadenopathy -- at our Disease Management Team meeting yesterday morning.O...
For a patient requiring adjuvant endocrine therapy for localized breast cancer, would you use fulvestrant if they were intolerant to both aromatase inhibitor and tamoxifen?
I think you may run into coverage issues since fulvestrant is not approved for the treatment of early breast cancer. For patients who don't tolerate AI or tamoxifen, I normally try Fareston (toremifene). I have a small handful of patients in my panel that have tolerated that when they haven't tolera...
Would you consider trastuzumab deruxtecan as next line of therapy for patients with ERBB2 mutation positive, stage IIIB NSCLC, who progress within 6 months of chemo- radiation?
Yes, I would consider trastuzumab deruxtecan as the next line of therapy for patients with ERBB2 mutation-positive, stage IIIB NSCLC, who progress within 6 months of chemo-radiation. We typically use recurrence within one year as the time frame between completion of chemo-radiation and recurrence fo...
For patients with NSCLC on osimertinib who progress, would you continue osimertinib when moving onto chemotherapy for 2nd line therapy?
It all depends if we have systemic vs non systemic acquired resistance. You can continue osimertinib if you have slow progression or oligomets can be treated with local therapy like radiation. Sometimes you can increase the dose to 160mg if only CNS progression and asymptomatic. In case of systemic ...
How do you manage hyponatremia in patients with renal cell carcinoma on cabozantinib and nivolumab?
Since ICPI can cause thyroiditis and adrenal insufficiency, the TSH and AM cortisol should be checked -- in addition to the usual evaluation for hyponatremia (serum and urine Osm, urine electrolytes, and an assessment of the patient's volume status). If adrenal insufficiency is present, the hyponatr...
How do you approach work-up for a patient suspected for monoclonal gammopathy of renal significance for whom renal biopsy is contraindicated?
Not very many reasons that a renal biopsy could not be done, but I would consider doing a bone marrow biopsy if the free light chain ratio was significantly abnormal, i.e. a ratio of 3 or greater. A reminder that in renal failure, both light chains may be elevated, but the ratio in benign processes ...
Would you consider antiphospholipid syndrome to be a contraindication for checkpoint inhibitor immunotherapy?
Checkpoint inhibitor therapy is usually an important treatment for patients with advanced malignancy, and has greatly improved the prognosis of otherwise untreatable cancers, so I would not automatically proscribe these drugs because of a history of APS. I would ensure patients with APS are on full ...
How would you treat a patient with recurrent DLBCL 15 years after definitive treatment of initial de novo disease with R-CHOP?
As a new primary DLBCL, but with previous exposure to 6 cycles of doxorubicin, I would only give RCHOP x 2, then RCEOP x 4. If interim PET showed a poor response, I would switch to a CAR T-cell therapy as 2L therapy.
Based on the results of SWOG S1801, neoadjuvant vs adjuvant pembrolizumab for resected stage IIIB-IV melanoma, are you starting to recommend neoadjuvant pembro for your patients?
Yes, I now usually would recommend neoadjuvant therapy for melanoma stage 3. If a clinical trial is open, I prefer to enroll patients in it. Patients who have contraindications to immunotherapy are treated with surgery first.
What adjuvant therapy would you offer following adjuvant chemotherapy for a patient with Stage III lung adenocarcinoma with an atypical EGFR mutation such as EGFR L861R?
Mutations at position 861 (most commonly L861Q) have been described, occurring in approximately 2% of all EGFR-mutant patients [Mitsudomi and Yatabe, PMID 19922469]. These mutations are considered partially sensitizing to afatinib based on a post-hoc analysis of LUX-Lung 2, LUX-Lung 3, and LUX-Lung ...