Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you refer all of your patients for EGD prior to initiation of atezolizumab/bevacizumab for advanced HCC?
Per the trial, this was required within 6 months of starting the study. However, in practice, I don't know that this strict rule would be necessary. For example, what if an EGD was done 10 months ago without varices? I don't think I would feel strongly about this. Similarly, if we could get one shor...
What are best practices for taking care of lung cancer patients during the COVID-19 pandemic?
This is a great question, and as always there is no one size fits all. For patients on active treatment for lung cancer such as chemoimmunotherapy, I continue to stress the importance of hand washing, social distancing, and to work on reducing wait times in the waiting room to limit exposure, etc. I...
How do you decide which immunotherapy agent to utilize for 1st line in PD-L1 high (>50%) NSCLC?
Now with the approval of atezolizumab based on the positive Impower110 study (led by @Dr. First Last and @Dr. First Last), we have 2 frontline checkpoint inhibitors to choose from. Indeed the data appears very convincing for both, therefore on scientific grounds, I would not be able to choose one ve...
For patients with cT1-T3 cN0 cM0 mid/low rectal cancer seeking organ preservation, what treatment approach do you recommend?
This is an important question; however, the answer is unknown. The key outcome that should be the focal point for the best treatment option, is which treatment strategy results in the most optimal patient reported quality of life and bowel function. Currently, this remains void of prospective, rando...
How do you follow/manage patients with metastatic prostate cancer with undetectable PSA and castration-sensitive but active disease on PSMA PET?
Summary: This is a challenging clinical scenario, and one in which I think there is currently a lot of practice variability. In such cases, I would not jump to action immediately, and I would first try to obtain some additional information. This would include repeat PSA for confirmation as well as f...
What measures should we take regarding routine follow-up visits for well patients in surveillance during the coronavirus pandemic?
3-6 months.
What is your standard approach for patients with platinum and ICI refractory small cell lung cancer?
For many years, my standard approach has be either topotecan or paclitaxel. I actually prefer paclitaxel over topotecan for patients with rapid progression after first line therapy. In refractory patients, the RR with topotecan in trials is only about 10% (which seems about right from my practice), ...
How would you treat rapidly growing inflammatory breast cancer, invasive lobular triple negative subtype, after two cycles of neoadjuvant KEYNOTE 522?
This is probably the single most difficult subtype of breast cancer to treat as it tends to be horribly chemo insensitive and molecularly most are actually luminal B and not basal. If growing on the carbon/Taxol/pembro portion of KEYNOTE, I would switch immediately to AC/pembro with a low threshold ...
Under what circumstances would you treat prostate cancer without a biopsy?
I largely agree with Dr. @Dr. First Last's comments as well as a prior post on this site in which anecdotes are cited of situations which falsely appeared suggestive of prostate cancer. As contemporary guidelines recommend treatment only in patients with localized prostate cancer with > 5-10 year li...
Are durva/cis/gem or pembro/cis/gem less efficacious in cholangiocarcinomas with FGFR2 fusions?
I have not been able to find an answer to this question. The NCCN and French National Clinical Practice Guidelines both continue to recommend first line treatment with Gemcitabine/Cisplatin and Durvalumab. Exceptions include NTRK gene fusions and MSI-H/dMMR where NTRK inhibitors (e.g. entrectinib, l...