Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
Do you defer bispecific antibody therapy in CAR-T-eligible patients with relapsed myeloma to keep CAR-T viable as a future option?
At this point in time, if I think that a patient is a good candidate for CAR-T therapy, I recommend that they pursue CAR-T prior to receiving a bispecific. Exceptions to this would be if there is a clinical trial available or if talquetamab is used as bridging therapy, but I would not administer a b...
Do you defer bispecific antibody therapy in CAR-T-eligible patients with relapsed myeloma to keep CAR-T viable as a future option?
At this point in time, if I think that a patient is a good candidate for CAR-T therapy, I recommend that they pursue CAR-T prior to receiving a bispecific. Exceptions to this would be if there is a clinical trial available or if talquetamab is used as bridging therapy, but I would not administer a b...
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Presently, the main categories of actionable DNA based alterations in advanced prostate cancer are 1) alterations in homologous repair enzymes like BRCA2, and 2) microsatellite instability (MSI high status, mismatch repair gene deficiency). These are actionable as they can lead to the use of a thera...
How do you manage multiple brain metastases from small cell lung cancer?
In general, I think WBRT is a reasonable treatment for small-cell lung cancer (SCLC) brain metastases. That being said, our institution has considered SRS for select patients depending on a variety of factors as the treatment paradigm for this is evolving. There have been some studies addressing SRS...
Before re-challenging a patient with ICI after grade 1-2 pneumonitis, do you re-image to confirm resolution of pneumonitis?
Grade 1 pneumonitis is defined as confined to one lobe of the lung or <25% of the total lung parenchyma, while grade 2 pneumonitis is defined as involving more than one lobe of the lung or 25-50% of the lung parenchyma. Grade 1 pneumonitis is typically an incidental finding on CT in an asymptomatic ...
Would you use upfront atezo/bev in a patient with HCC and untreated hepatitis?
Yes. I would not have concerns. For HBV, I would start treatment before or simultaneously. Studies have varied by protocol about the HBV viral load being under 500 or 100 but it is not clear this matters. There have not been flairs reported. In regards to HCV, again, not an issue for me.
Do the higher rates of grade 1–2 pulmonary fibrosis with hypofractionated PMRT in CHN HYPOPMRT change how you counsel patients about long-term lung toxicity when choosing between fractionation schedules?
The higher rate of grade 1-2 pulmonary fibrosis with hypofractionated postmastectomy radiotherapy in CHN HYPOPMRT does not change my recommendation. The excess toxicity is confined to grade 1-2 disease—largely radiographic or mildly symptomatic fibrosis. Importantly, the abstract reports grade 1-2 f...
Given the equivocal findings of NRG GI003, in which patients would you select for liver-directed proton therapy in the management of HCC?
Based on the results presented, there is not an indication to routinely recommend proton-based radiation for HCC. There are ongoing efforts to see if there is a subgroup that benefits from protons.
For large HCCs, if the normal tissue complication probability is unacceptably high for a 5-fraction photon SBRT plan but is acceptable for a 5-fraction proton SBRT, would you recommend 5 fractions of protons or 15 fractions of photons?
No, this is not recommended in light of the unexpected finding that patients with tumors over 5 cm had a worse outcome with protons on multivariable analysis. This finding is puzzling, and we will be doing further analysis to understand it.