Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the current paradigm for breast cancer diagnosed with isolated metastases prior to initial treatment?
Surgery of the primary did not significantly improve overall survival in which patients were randomly allocated to receive systemic therapy alone or (for responding patients) to systemic therapy followed by primary tumor resection in the trial conducted by ECOG-ACRIN (Khan et al., PMID 34995128), at...
Are there reasons to not use prostate SBRT when treating the prostate +\- proximal SV?
Early trials such as HYPO-RT-PC which aimed to validate a 7-fraction SBRT dose schedule by comparing it to the standard of care at the time, conventionally fractionated EBRT, utilized a treatment volume consisting of the prostate alone without the seminal vesicles (SVs). While there was some suggest...
What is the optimal duration of ADT for unfavorable intermediate risk or high risk localized prostate cancer treated with SBRT instead of conventionally fractionated or hypofractionated RT?
There is no available data from randomized trials to support any modification in the choice of ADT (GnRH agonist vs antagonist) or use of abiraterone acetate, or on the duration of ADT (4-6 mo vs 2-3 years) based on the form of radiation, and thus I follow the NCCN guidelines that provide recommenda...
Is there adequate evidence for the use of PARPi in combination with ARSI for BRCA+/HRR mutated mCRPC as compared to sequential therapy?
This question is phrased perfectly: the important consideration is whether sequential therapy would be just as good, i.e. the "old" standard of care. Unfortunately, this is not how the three trials cited above were designed. Control-arm HRRm patients were assumed to have access to PARPi post-protoco...
How are you choosing between ipilimumab/nivolumab versus platinum/pemetrexed for unresectable epithelioid mesotheliomas?
Although the combination of ipi/nivo has been approved for all unresectable mesotheliomas, the benefit was much more impressive in the NON-epithelioid histologies. Therefore, for patients with epithelioid mesothelioma, I follow the NCCN recommendations where I would discuss both platinum/pemetrexed ...
Would you consider neoadjuvant chemotherapy for patients with muscle-invasive bladder cancer who are cisplatin-ineligible?
We have level 1 evidence supporting neoadjuvant cisplatin-based chemotherapy followed by cystectomy, there is no evidence supporting non-cisplatin based chemotherapy. Patients unfit for cisplatin should proceed directly to surgery.
For patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?
So, this is a challenging question – actually two questions – 1) unable, 2) refuse. With respect to unable, this typically would (I assume, and in my practice) refer to patients whose functional status is sufficiently poor to prevent one from giving chemotherapy along with radiation. Note that esse...
How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?
In the PACIFIC study, 713 patients who received at least 2 cycles of platinum-based chemotherapy with radiation (CRT) and did not develop disease progression were randomly assigned in a 2:1 manner to receive durvalumab at 10 mg/kg every 2 weeks up to 12 months or placebo. Randomization took place be...
How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?
Generally, the first imaging post chemoradiation (CRT) would have been performed about 6-8 weeks following completion, and this has changed as we start durvalumab within 42 days following CRT. I perform a baseline CT chest prior to starting durvalumab. I proceed to monitor with CT chest about every ...
How do you manage a delayed cutaneous reaction to docetaxel after the first cycle of adjuvant TC in early-stage HR-positive, HER2-negative breast cancer?
There is excellent guidance in the literature on management of drug-induced rashes in these patients in Sibaud et al., PMID 27550571. Management generally involves topical and if necessary systemic steroids. I particularly like using lotion versions of topical steroids such as triamcinolone as they ...