Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to a patient with metastatic lung cancer with HER2 mutant NSCLC who is not a trial candidate?
For newly diagnosed (first line regimen), I would offer either platinum doublet chemotherapy or chemo-immunotherapy (i.e. KN189 regimen) although I might be a little bit more hesitant to do immunotherapy while we figure out the risk factors associated with developing ILD from use of trastuzumab deru...
Do you offer IV iron first line to women with iron deficiency anemia from heavy menstrual bleeding?
I offer first-line IV iron because oral iron cannot keep up with the losses from heavy menstrual bleeding, and the majority can't tolerate it. I routinely give a gram of LMW iron dextran in one hour, Feraheme (not ferumoxytol generic) 1,020 mg in 30 minutes, or ferric derisomaltose 1 gram in 30 minu...
How would you approach adjuvant systemic therapy for an isolated, oligometastatic CNS recurrence of RCC that was treated with SBRT?
I tend not to treat patients with resected/irradiated CNS lesion(s) if there is no disease elsewhere. Such patients were not included in the adjuvant pembro study, the activity of any systemic therapy for CNS disease is not well-established, and in general, I worry single agent pembro is undertreatm...
Do you do prophylactic LP/IT chemotherapy in high risk APML prior to starting consolidation?
Extramedullary disease such as CNS involvement is quite uncommon at diagnosis in acute promyelocytic leukemia (APL). However, it can be seen in patients with relapsed disease. Both isolated CNS relapse and CNS relapse associated with morphologic or molecular relapse can occur. Yet one has the impres...
Do you do prophylactic LP/IT chemotherapy in high risk APML prior to starting consolidation?
Extramedullary disease such as CNS involvement is quite uncommon at diagnosis in acute promyelocytic leukemia (APL). However, it can be seen in patients with relapsed disease. Both isolated CNS relapse and CNS relapse associated with morphologic or molecular relapse can occur. Yet one has the impres...
Are there patients for whom CROSS followed by surgery and adjuvant nivolumab should still be considered, following data from MATTERHORN and ESOPEC?
ESOPEC does not invalidate CROSS—it redefines the preferred option for fit patients; in the real world, not every patient will be able to tolerate FLOT or d-FLOT: Yes. Despite the emergence of perioperative FLOT-based strategies from ESOPEC and MATTERHORN, CROSS, followed by surgery and adjuvant niv...
How do you differentiate between ERBB2 mutation vs HER2 overexpression testing when selecting patients for tumor-agnostic therapy?
This distinction is critical. HER2 protein overexpression (IHC ± ISH) underpins T-DXd’s tumor-agnostic approval. ERBB2 mutations define a different subset that perhaps may have better responses to HER2 TKIs that are in development rather than ADCs. In other words, a genomic alteration in ERBB2 does ...
Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?
Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doin...
Do you continue bortezomib past 8 cycles for transplant ineligible patients with multiple myeloma on VRd who are tolerating therapy well with no neuropathy?
Excellent question without a clear answer. While several RCTs have looked at post-induction maintenance among patients without planned transplantations, the British Myeloma XI trial is the biggest RCT (to my knowledge) to clearly look at lenalidomide vs observation in transplant-ineligible patients....
How do you manage grade 2-3 chemotherapy- induced peripheral neuropathy (CIPN) developing during adjuvant paclitaxel therapy for breast cancer?
In cases with grade 2-3 neuropathy, I consider dose reduction of paclitaxel by at least 20%. I have also used duloxetine (30 mg daily for the 1st week and then 60 mg daily based on the randomized study by Smith et al (JAMA 2013)), with fair amount of success. I have also used gabapentin, although wi...