Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the appropriate monitoring for an incidental low-grade rectal neuroendocrine tumor resected endoscopically with positive margins?
Do we have information on the size of the lesion? Typically, if it was a positive biopsy and the size of the polyp was <1 cm, we typically rescope and biopsy the scar. It can harbor residual disease (40% incidence), which a deeper resection can cure. And then these patients don't need surveillance. ...
Among the metastatic/unresectable melanoma patients you would historically treat with anti-PD-1 monotherapy, are you now recommending nivolumab/relatlimab instead?
Based on the published RELATIVITY-047 study, the nivo/rela combination leads to a superior median PFS of 10.2 mo (vs 4.6 mo for nivo alone) - both updated at ASCO 2022. At the most recent update at the ASCO 2022, the median survival has not been reached yet for the patients treated with nivo/rela (v...
How would you treat a patient with newly diagnosed stage IV NSCLC who has an activating mutation in the ERBB2 extracellular domain and a concurrent classical EGFR mutation?
No high-level evidence/guidelines for such a situation since oncogenic ECD mutation in HER2 itself is quite uncommon (approximately <10% of HER2 mutations [Robichaux et al., PMID 31588020]), and co-occurrence with classical EGFR mutation will be even less common. Will generally treat based on the cl...
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
How will you select patients with brain metastases for TTFields?
The METIS trial restricted eligibility only to patients with brain metastases from non-small cell lung cancer. Therefore, we would not be able to extrapolate these results and data to other tumor types and histologies. Indeed, a post hoc analysis of the data did demonstrate a greater impact in patie...
How long would you anticoagulate a patient with recurrent VTE who has ongoing risk factors for intracranial bleeding?
In general, my preferred agent outside of the inpatient setting in patients with a risk of intracranial bleeding is LMWH. In the inpatient setting, utilizing a bivalirudin or heparin gtt is most appropriate. I would monitor carefully, including potentially imaging 24 hours after the therapeutic anti...
Would you recommend the SOFT/TEXT adjuvant approach of ovarian suppression/AI in a premenopausal woman with high-risk disease who still desires to have a pregnancy?
In the SOFT trial, the disease-free survival impact of adding ovarian suppression to hormonal therapy was not statistically significant in the overall population, but was superior in higher risk patients, including those who received chemotherapy. While we typically do not guide treatment based on s...
Can immune checkpoint inhibitors be safely given in a patient with chronic GVHD?
If the patient has active chronic GVHD the risk-benefit ratio of immune checkpoint blockade needs to be carefully assessed since there are well documented instances of severe GVHD flairs or immune-related adverse effects - in a patient on chronic immune suppression and quiescent GVHD we recommend no...
What chemotherapy would you consider to treat platinum resistant high grade serous ovarian cancer in patients with a low grade MDS from prior platinum/PARPi?
Before making a recommendation to this patient, a basic understanding of treatment related MDS/AML is needed, along with a clarification of the meaning of “low risk of progression to acute myeloid leukemia (AML)”. My main goal would be to avoid therapy with a demonstrated risk of treatment related M...
Do you hold nivolumab and ipilimumab when giving palliative radiation to abdominal targets?
This is similar to the question of whether you should hold bevacizumab for palliative radiation. You cannot really change the biologic effects of these agents immediately by holding them. The toxicity has been repeatedly shown to be minimal in trials where radiation has been included with concurrent...