Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach for perioperative chemotherapy in MSI-H/dMMR localized gastric cancer?
This question gets at aspects of MSI-H biology, biomarker testing and post-hoc data from the MAGIC and CLASSIC trials suggesting a lack of benefit, and potential negative impact of treatment in MSI-H patients. The following is restricted to gastric cancer, and the rates of MSI-H in true esophageal a...
How do you manage the side effects of ropeginterferon alfa 2b for polycythemia vera patients?
Great question. Although ropeginterferon is better tolerated than other interferons, it is still associated with adverse events. If counts are controlled, I would recommend lowering the dose or spacing out the dosing interval, as that usually helps. For flu-like symptoms, I recommend pre-emptive man...
How do you manage the side effects of ropeginterferon alfa 2b for polycythemia vera patients?
Great question. Although ropeginterferon is better tolerated than other interferons, it is still associated with adverse events. If counts are controlled, I would recommend lowering the dose or spacing out the dosing interval, as that usually helps. For flu-like symptoms, I recommend pre-emptive man...
What would your initial treatment be for an elderly patient with metastatic HER2+ GEJ cancer with PD-L1 <5 who cannot tolerate any platinum agents?
The current standard-of-care is based on the KEYNOTE-811 study, which established the combination of pembrolizumab with trastuzumab and a fluoropyrimidine/platinum doublet for tumors with a PD-L1 CPS of 1 or more. Very recently, trastuzumab has been replaced in the first-line setting by the results ...
For metastatic cholangiocarcinoma that has progressed on first line chemotherapy and immunotherapy, that is HER2 3+, which HER2 regimen is preferred, TDxD, Zanidatamab or tucatinib/trastuzumab?
With the studies specific to cholangiocarcinoma with these agents and risk profile, I’d favor the bispecific Zanidatamab over the antibody drug conjugate T-DXd.Smolenschi et al., PMID 40319675The pneumonitis/ILD is still a black box warning for the ADC and varies between 5-15% depending on which stu...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...
Can post op RT be omitted in a surgically repaired pathological fracture site in multiple myeloma if the patient will receive systemic therapy?
For extremities (e.g., the femur), if the pain is largely from structural instability, which resolves after surgical stabilization, then proceeding with systemic therapy without post-op RT would be very reasonable. On the other hand, if the patient is having persistent pain after surgery from the os...
What risk factors would favor the addition of ovarian function suppression to endocrine therapy in triple-positive breast cancer?
Young age less than 40, node positive, high-grade, bulky tumor, or any patient at high risk of recurrence (requiring chemo) or residual tumor, I would favor giving ovarian suppression as per the SOFT and TEXT trial.
What is your approach to pregnant patients with type 2B von Willebrand disease, particularly when thrombocytopenia is already present?
The gist of this challenging clinical problem is that the high estrogen levels in the third trimester of pregnancy raise the VWF level normally. In type 2B VWD, this effect raises the level of the abnormal VWF, which clears more platelets from the circulation, and can lead to severe thrombocytopenia...
What radiation doses and subsequent treatment monitoring would you recommend for multiple myeloma patients with multifocal bony lesions who decline chemotherapy?
Systemic therapy is the cornerstone of treatment for multiple myeloma, and the vast majority of patients initiate an appropriate regimen upon diagnosis. Occasionally, patients will have very limited disease and will be referred to Radiation Oncology for consideration of local therapy to delay the ne...