Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider a PARP inhibitor in the treatment of a PARP inhibitor naïve platinum resistant recurrent ovarian cancer with LOH/HRD?
These are challenging scenarios and with increasing PARP use in the upfront setting, especially (likely) in the LOH/HRD patients I suspect this clinical scenario may become less frequent in the future. For now, it's appealing to suggest that LOH/HRD scores as a biomarker can be examined in a vacuum ...
Would you consider adjuvant chemotherapy in the management of retroperitoneal leiomyoscarcoma who did not respond to neoadjuvant doxorubicin/dacarbazine?
If pre op ADIC failed and the RP LMS is completely resected with NED, I would just pursue close observation.
How would you treat a patient with T4N1M0 GEJ adenocarcinoma with local progression after concurrent chemoRT who still has resectable disease?
This is a tricky but thankfully rare scenario.My answer depends on the nature of the local progression. The more favorable situation involves local persistence of the primary tumor with a modest increase in locoregional lymph nodes. This situation would essentially represent a lack of response to ch...
Would you consider CAR-T therapy without autologous transplant in a patient with multiple myeloma whose best response to induction therapy is a partial response?
Excellent question that will be even more pressing in ~2024 (maybe earlier!) as we get more data and possibly more FDA/insurance approvals here. For now, the only way to get second-line CAR-T for inadequate response to frontline induction is on a clinical trial - and several such single-arm trials a...
Would you offer adjuvant capecitabine in a patient with nasopharyngeal carcinoma who has had cisplatin - gemcitabine induction followed by chemoradiotherapy with cisplatin?
There are now two randomized, published studies in patients with locally advanced nasopharyngeal cancer whereby capecitabine is administered in the adjuvant setting [1], [2]. Both studies demonstrate adjuvant capecitabine improves failure free survival or local control of disease. The combination of...
Would you provide the KEYNOTE-522 regimen for a patient with ER low, PR+, HER2- stage IIIb breast cancer?
I think it is reasonable to use the KEYNOTE-522 regimen for a patient with stage IIIB breast can with a tumor that is ER-low (<10%), PR+ and HER2-negative, but with many caveats. Both biological and clinical outcomes data suggest that such cases are closer to HR-negative (as is ER-/PR+ disease). (1,...
What is the optimal treatment strategy for patients with stage IV NSCLC who have an actionable molecular target identified after initiation of first-line systemic therapy?
I am assuming that immune checkpoint inhibitors were held while molecular results were pending based on evolving literature in the field (Calles et al., PMID 32421452). My personal recommendation is to complete 2-4 cycles of platinum doublet chemotherapy and obtain repeat imaging after completing th...
How do you approach treatment for a patient with hypoplastic MDS who is not eligible for transplant?
I believe it is reasonable to try immunosuppressive therapy particularly if the patient is positive for HLA-DR15. I would treat such a patient with triple immunosuppressive therapy with horse ATG, cyclosporine, and eltrombopag (de Latour et al., PMID 34986284) if they are HLA-DR15 positive. If they ...
Are there concerns in use or dosing of immunotherapy agents in extreme obesity?
I do not have a threshold for dosing based on BMI. Flat dosing is now typically used for single agent immunotherapeutic agents such as durvalumab. We still do not know the optimal dosing, schedule, or duration of therapy defining the use of immunotherapy in general. There are reports that obesity is...
When planning to give adjuvant nivolumab for esophageal cancer, would you be comfortable with nivolumab with q4 weekly dosing as opposed to q2 weekly dosing?
I generally start with Q2 week dosing - as per the BMS CheckMate 577 protocol - so that I can make sure that there is not any immediate toxicity. In the study, the dosing was Q2 weeks until 16 weeks and then it moved to Q4 weeks. If a patient is doing well, I have moved to Q4 week dosing at 8 weeks ...