Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage monitoring menopausal status for a premenopausal patient with DCIS on tamoxifen who would likely become post-menopausal during therapy?
Monitoring menopausal status in premenopausal women on tamoxifen is relatively easy, even if the tamoxifen interrupts their menstrual cycles, or they have had a hysterectomy but still have at least 1 ovary. Since tamoxifen doesn't lower estrogen levels the way aromatase inhibitors do, you can simply...
How do you choose between Atezolizumab/Bevacizumab (IMbrave 150) versus Durvalumab/Tremelimumab (HIMALAYA) versus Ipilimumab/Nivolumab (Checkmate09DW) in first-line metastatic hepatocellular cancer?
I use a range of factors, discussed here and here, when deciding between atezo/bev and STRIDE regimens in my patients with advanced HCC.Summarily, both regimens demonstrated clinical benefit in patients with advanced HCC with side-effect profiles expected for the individual agents. The choice of reg...
Are there any special considerations for treatment of metastatic acral melanoma?
In general, acral melanoma is a higher-risk disease. There are higher rates of acquired and primary resistance. Given this, I favor ipi-nivo since the overall risk is higher and response rates to single-agent PD-1 or nivo-rela tend to be lower. Emerging data suggest TIL therapy can work reasonably w...
What is the role for chemoimmunotherapy in the up front setting in non-metastatic head & neck cancer outside of clinical trials?
Phase III studies of immunotherapy concurrent with chemo-RT vs chemo-RT alone, JAVELIN Head and Neck 100 and KEYNOTE-412, didn’t demonstrate a survival benefit of the immuno-containing regimens (while post hoc analyses suggested that PD-L1 positive patients may have benefited). These studies did not...
What neoadjuvant therapy will you give to a premenopausal woman with cT2N0 metaplastic triple negative breast cancer?
A stage 2 metaplastic TNBC is considered a high risk, relatively chemorefractory rare subtype case with limited data regarding optimal treatment. Multiple studies have shown metaplastic tumors demonstrate higher levels of PDL1. (Grabenstetter et al., PMID 34115674) Sylvia Adams has published some re...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
How do you counsel a patient diagnosed with HTLV after an abnormal blood donor screening, especially in light of new data that dolutegravir may reduce uncommon but severe neurological outcomes associated with infection?
We actually do not see many individuals with HTLV disease at present in the US. Having said that, HTLV is a retrovirus, so it is biologically plausible that integrase inhibitors (like dolutegravir) could reduce viral spread in the body. However, the key counseling message is: evidence is still emerg...
Do you need renal biopsy before SBRT for RCC suspicious cancer?
Yes. The teaching is usually that ≈ 20% of small renal masses (<4 cm) are benign, and this rate goes down as size increases (Thompson et al., PMID 19286217). Features such as contrast enhancement, tumor location, and sex can help to improve the malignant risk potential of these lesions, but no combi...
Would you recommend adjuvant immunotherapy after platinum-based chemotherapy for patients with in resected NSCLC with HER2 mutations?
The benefit of immunotherapy in HER2 mutant NSCLC is an active topic of debate. I do not typically recommend adjuvant immunotherapy after platinum-based chemotherapy for patients with resected HER2-mutant NSCLC. Tumors with oncogenic drivers, specifically EGFR, ALK, ROS, RET, and HER2, show reduced ...
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
I do not offer consolidation chemotherapy to patients prior to durvalumab in patients with locally advanced, unresectable NSCLC. The PACIFIC trial was a randomized phase III trial that established the role of consolidation durvalumab after definitive chemoradiation for patients with stage III NSCLC....