Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Given the results of LU002 presented at ASCO 2024, are there situations and/or patient subgroups who still derive benefit from local consolidative therapy for oligometastatic NSCLC?
This is a tricky trial to interpret. They allowed a mixture of "stage I" primaries with oligomets and "stage III" locoregional disease with oligomets. The former got SBRT to the primary and the latter got 45 Gy/15 fx to primary and involved LN. There is a huge difference in the "ablativeness" of tho...
In a patient with prior RT to the prostate and SVs and newly diagnosed, locally advanced rectal cancer at 10-15 cm, would you offer preoperative chemoradiation?
"Locally advanced" rectal cancer was traditionally described as T3/4N0M0 or TxN+M0 cancer, but we have advanced much farther on the characterization of this now.We also know that the local control of patients undergoing resection for high rectal cancer (10-15 cm from the anal verge) is much better t...
How would you manage HHT with ongoing epistaxis despite IV bevacizumab, with a history of superficial thrombosis?
This is a complex situation with a complex answer, and the patient would likely benefit from establishing care at one of the 30 HHT centers of excellence for a more thorough evaluation. If the patient mentioned has only had cautery, we would consider them seeing an ENT at an HHT center of excellence...
Are you altering your use of immune checkpoint inhibitors given the risk of immune-related pneumonitis and the COVID-19 outbreak?
Nivolumab can be used every 4 weeks rather than every 2 weeks. We have to be flexible and change our approach according to circumstances.
For patients with EGFR mutation positive NSCLC who progress on first line TKI without actionable resistance mechanisms, would you consider chemotherapy + targeted therapy as a second line option, or chemotherapy +/- immunotherapy?
Although the question assumes no actionable changes in the lung cancer, I do refer you to an excellent review of this topic, published last September (Piper-Vallillo et al., PMID 32552277), which included a table listing twenty-five open clinical trials for patients who have developed progression af...
Would you consider adding gabapentin off label for use in the treatment of glioblastoma at this time?
As an author on the paper, let me emphasize the findings and speculate on the implications. Recently, a number of laboratories have unraveled stunning preclinical and mechanistic findings demonstrating the ability of a subset of malignant glioma cells to usurp neuronal circuitry to promote tumor gro...
Can you use immunotherapy in patients with liver transplants?
Treating metastatic melanoma in the setting of organ transplantation is indeed difficult. I work with the transplant physicians to reduce immune suppression as much as possible and see if the mTOR inhibitors can be used. I would be sure to explore all targetable mutations (BRAFV600E or K, c-KIT) an...
How do you counsel glioblastoma multiforme patients on which types of clinical trials to pursue?
This is a great question! In general, I think that a clinical trial gives someone access to promising therapies (and of course glioblastoma is an aggressive tumor for which we have no cure), but enrolling in one may not feel like the right decision for all patients (for a variety of reasons). I thin...
How would you treat a patient with ER/PR positive breast cancer with a single site of bone metastasis?
I would still treat with hormone therapy and a CDK 4/6 inhibitor. Not clear if the question refers to denovo disease or not. I generally do not treat asymptomatic bone mets with radiation, as there are late effects in patients who have a relatively long life expectancy and no data to suggest that ra...
Are you routinely recommending adjuvant ribociclib now for node-negative HR+/HER2- breast cancer given data from the NATALEE trial?
Yes, I offer eligible node-negative patients, as defined by the NATALEE trial criteria, with anatomic stage II or III hormone receptor-positive breast cancer node-negative patients who are at high risk of recurrence, as defined by and would have met criteria for the NATALEE trial.The NATALEE trial d...