Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant therapy would you offer for a cisplatin-eligible patient with upper tract urothelial carcinoma and Lynch Syndrome?
Good question and discussed it with Dr. @Dr. First Last. We have seen data from the POUT phase 3 trial (Birtle et al., PMID 32145825) showing significant DFS benefit with adjuvant Gem/Cis vs observation after radical surgery (due to study closure the trial was not powered to show OS benefit) in pati...
For a patient with metastatic colon cancer which is MSI-H/dMMR and BRAF V600E+, what would be your preferred first line treatment?
In line with current NCCN guidelines, I would treat all MSI-H patients, regardless of their BRAF status, with immune checkpoint therapy in first-line unless there were clear contraindications. BREAKWATER excluded MSI-H patients, so this data should not be extrapolated to MSI-H/BRAF V600E mutated pat...
Do you recommend progesterone for endometrial protection in a young woman on estrogen replacement therapy for iatrogenic menopause after definitive radiation therapy for locally advanced cervical cancer?
For women with a uterus, I give a combination of estrogen and progesterone therapy, even after definitive radiation therapy. Transdermal preparations have the advantage of bypassing first-pass effect of the liver, but oral combinations are also acceptable.
In which patients will you consider the use of adjuvant pertuzumab for HER2 positive early stage breast cancer?
The benefit of adding pertuzumab to a trastuzumab-based regimen is quite small (0.9% at 3 years, 1.8% in those with involved LNs). This will not change my practice for most patients. Certainly for a patient with multiple involved nodes and ER- disease, the addition of pertuzumab will become a long d...
How does pirtobrutinib compare to other available therapies for relapsed/refractory CLL after BTK inhibitor treatment, particularly in terms of efficacy and tolerability?
BRUIN trial enrolled patients with a median of 3 prior lines of treatment. The response rate with pirtobrutinib is close to 80%. However, overall PFS is about 1.5-2 years. So, most patients will eventually relapse after pirtobrutinib.It is possible that the use of pirtobrutinib in earlier lines of t...
How does pirtobrutinib compare to other available therapies for relapsed/refractory CLL after BTK inhibitor treatment, particularly in terms of efficacy and tolerability?
BRUIN trial enrolled patients with a median of 3 prior lines of treatment. The response rate with pirtobrutinib is close to 80%. However, overall PFS is about 1.5-2 years. So, most patients will eventually relapse after pirtobrutinib.It is possible that the use of pirtobrutinib in earlier lines of t...
Would involved site radiation therapy be recommended in a patient with POEMS syndrome whose myelopathy symptoms worsened after one cycle of CyBorD?
I would swiftly treat this patient with a common schedule, for instance, 5 x 4 Gy. I do not see any risk of concurrent rituximab.
Would you consider omitting concurrent chemoradiation for a patient with stage III EGFR-mutant NSCLC and initiating treatment with osimertinib instead?
No. Osimertinib alone is a palliative treatment with limited durability, which is not appropriate as first-line therapy for a patient who is interested in and eligible for definitive treatment. While the outcomes of the control arm of chemoradiotherapy without osimertinib in the LAURA trial were cer...
How are you considering use of inavolisib/palbociclib/fulvestrant over ET doublets for patients with high risk disease features such as visceral metastases, visceral crisis, high tumor burden?
I would favor deployment of the triplet regimen from the INAVO120 trial in a real-world patient population that mirrors the inclusion criteria for the clinical trial. For example, I would utilize this in routine clinical practice for patients on adjuvant endocrine therapy (typically with an aromatas...
How does the CLL17 trial presented at ASH 2025 change current practice guidelines?
The CLL17 study provides some tangential support for time-limited therapy in a subset of patients that I would consider now--those who have low-risk disease with IGHV mutated (non-3-21) and absent TP53 mutation or deletion. Here, we would expect patients to do quite well, and long-term follow-up exi...