Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When would you offer single fraction adjuvant partial breast irradiation instead of a 5-10 fraction course for early stage breast cancer?
We have not offered a single fraction, and our standard is 26 to 30 in 5 fractions. Data on a single fraction is not enough to support this recommendation for now.
What is your radiation approach to metastatic pancreatic tail adenocarcinoma s/p gem/abraxane and FOLFIRI now with an oligo-progressive LUL lung metastasis?
I certainly would favor metastasis-directed therapy with SBRT, given the PFS benefit observed in EXTEND, and I think the case for utilization in the oligoprogressive state is even stronger pan-tumor compared to consolidative treatment. I'd treat 50-55 Gy/5 fractions or could consider fractionating o...
If approved, in what settings will you consider adding aglatimagene besadenovec (CAN-2409) to EBRT as an ADT-sparing strategy in prostate cancer treatment?
PrTK03 (NCT01436968; DeWeese et al., PMID 42225101) was a phase 3 RCT randomizing patients with either NCCN intermediate or high-risk prostate cancer (>1 HRF excluded) to RT ± CAN-2409, which is an adenoviral-based immunotherapy delivered with a prodrug (valacyclovir) and stratified by NCCN risk gro...
In a patient with high-risk cutaneous squamous cell carcinoma of the face with extracapsular extension after ipsilateral neck dissection and rapid contralateral cervical nodal recurrence, what is the optimal management?
In various published series, around half of patients fail to achieve a complete response to cemiplimab. From the clinical details, the current active area of disease appears to be the contralateral neck with no distant disease. Curative treatment is preferred. C-POST trial established surgery + adju...
What is your protocol for type of surveillance imaging (CT/MRI/PET) and frequency of follow-up after SBRT to a bone metastasis?
I typically have approached decisions regarding surveillance based on the site (i.e., spinal vs. non-spinal bone metastasis), indication for SBRT (i.e., definitive or post-operative, particularly in spinal metastasis patients who required initial debulking), and primary site (i.e., radiosensitive, s...
What neoadjuvant strategies do you utilize for initially unresectable biliary tract cancer?
Great question. While there is not prospective data, I tend to use the triplet chemo regimen of gem/cis/nab-paclitaxel based on the 20% conversion rate seen in this phase 2 study. There is an ongoing neoadjuvant study in IHCC that is investigating the triplet, but this is only open at select centers...
In a patient with esophageal cancer with lymph node involvement, would you consider treating with definitive chemo-radiation if they have a single area of retroperitoneal metastasis?
If a patient has non-regional retroperitoneal adenopathy without other distant metastasis (i.e., below the level of the celiac axis), that patient has M1 disease, and upfront definitive chemoRT would no longer be the standard of care (systemic therapy alone would be). However, I would then consider ...
If zolbetuximab was not given in first line in metastatic gastric cancer with CLDN 18.2, would you give it with second line ?
The short answer is no. Available data in later lines have shown essentially no single-agent activity (Klempner et al., PMID 37490286). Because zolbetuximab is a chimeric (mouse/human) IgG1 naked antibody that relies entirely on immune effector mechanisms (ADCC and CDC) to kill tumor cells, it does ...
Does receiving IVIG confound the result of SPEP and/or UPEP?
IVIG being a product of polyclonal immunoglobulins may ‘produce’ a monoclonal spike if the AUC is falsely calculated by the reader. IFE usually shows polyclonal banding but every now and then a monoclonal band is picked up. Being an IgG molecule with a 21 day halflife; and with the assumption that i...
Is there a correlation with severity of rash as an adverse event and response rate with capivasertib?
While it is tempting to hope that patients with significant side effects on targeted therapies might be more likely to demonstrate an antitumor response to that treatment, and there is limited data to suggest a possible correlation between immune-related adverse events and response to immunotherapy,...