Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Can ctDNA be used to evaluate response to checkpoint inhibitors in NSCLC when pseudoprogression is suspected on CT imaging?
This is a scenario where ctDNA may have value in the future, as imaging alone is often not sufficient to reliably differentiate between pseudo-progression and true progression in patients receiving immune checkpoint inhibitors. A small study of 28 patients with melanoma suggested that ctDNA obtained...
Which patients would you treat with relugolix instead of injectable GnRH agonist therapy?
I would consider relugolix for patients with: 1. Intermediate-risk prostate cancer that needs a short course of androgen deprivation therapy 2. Patients with biochemical relapse that would benefit from a short course of ADT and salvage RT2.5 Patient with pre-existing cardiac comorbidities 3. Potenti...
Will you offer capecitabine for 1 year to all localized TNBC patients?
The SYSUCC trial enrolled stage Ib-III TNBC patients who had either neoadjuvant or adjuvant systemic treatment followed by standard local therapy, and randomized the patients to either get 1 year of metronomic dosed capecitabine (650mg/m2 BID no break) x 12 months or observation. They observed an im...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
Which adjuvant chemotherapy regimen would you recommend for a peri-menopausal woman with synchronous stage IA primary breast tumors, one that is ER+HER2+ and the second ER+HER2-?
I would treat the patient with paclitaxel 80mg/m2 x 12 weeks plus trastuzumab for a year (Tolaney et al., Clin Oncol 2019). The more difficult question is the optimal anti-estrogen therapy: tamoxifen (TAM), TAM + ovarian suppression (OS), or aromatase inhibitor (AI) + OS. This is because the SOFT an...
Should 3 years of adjuvant osimertinib be the standard of care for resected Stage IB-IIIA EGFRm NSCLC?
Since my initial response to this question, the ADAURA study has been fully published (NEJM 383:1711, 2020) and the FDA has approved osimertinib as adjuvant therapy for people with resected NSCLC harboring an EGFR sensitizing mutation. However, neither of these events has altered my opinion that des...
What is your preferred first-line therapy for transfusion-dependent beta-thalassemia?
Transfusion is my preferred first-line therapy (and standard of care) for beta-thalassemia major. For beta-thalassemia intermedia that has evolved into TDT, my preferred first-line treatment is mitapivat over luspatercept, particularly if the patient has extramedullary masses (that have been noted t...
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...
Would weak PR positivity make you consider adjuvant endocrine therapy for a young pre-menopausal woman with a HER2 positive, ER negative breast cancer?
I would discuss the uncertainties, and would offer tamoxifen at the most (I would not subject the patient to the toxicities of OFS and AI). I would also have a low threshold to discontinue tamoxifen if there are toxicities. If there are minimal to no side effects, it may be worthwhile getting the th...
For patients starting Pluvicto, do you have patients stop their ARPI?
While the VISION trial allowed for concomitant use, it was only about half (53%) in the Lu-177-PSMA arm, and 2/3 (68%) of those on the standard of care arm - Garje et al., PMID 36693228. And the PSMAfore trial did not, as noted above by @Dr. First LastThe bigger question is, will you continue the AR...