Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you recommend 3 months of chemotherapy, 6 months of chemotherapy, or no chemotherapy along atezolizumab in patients with low risk (T1-3, N1) Stage III dMMR colon cancer?
This is a good question (and a data-free zone). pMMR low-risk stage III disease can be treated with 3 months of CAPOX or 6 months of FOLFOX, based on the IDEA trial. The residual risk of relapse for this entity, after chemotherapy, is ~20%. FOLFOX for 3 months was inferior to 6 months by a few perce...
What is the maximum dose that you would give to residual unresectable gross disease in the axilla in the setting of recurrent breast cancer s/p ALND?
The FAST-Forward boost trial will be informative here, and I would recommend reading the protocol, because one can consider using the standard arm now, which is 40 Gy to the breast (and nodes, when RNI is indicated), and a 48 Gy boost, all in 15 fractions. This dose is recognizable as the breast boo...
How are you approaching endocrine therapy for patients with metastatic HR+/HER2+ breast cancer in light of enhanced HER2 directed treatment with either T-DXd/pertuzumab or HP/tucatinib?
This is an area without clear data. I am not entirely sure that it matters. While the S8814 trial demonstrated that sequential chemotherapy followed by endocrine therapy (tamoxifen) was the best arm, this question has not been fully addressed with aromatase inhibitors. I typically would start ET wit...
How do you monitor for pulmonary toxicity for patients on trastuzumab deruxtecan?
Eligibility criteria for T-DXd trials were based on clinical history and not on objective findings such as PFTs or radiographic criteria. Therefore, risk for factors for T-DXd-related ILD or other pulmonary toxicity are not at all clear, although they may emerge with larger pooled safety analyses an...
Would you give adjuvant pembrolizumab in a MSI-H oligometastatic colorectal cancer status-post resection that responded to neoadjuvant ICI?
Only <5% of metastatic colorectal cancer is mismatch repair deficient (dMMR) or microsatellite instability-High (MSI-H). However, it is such an important predictive biomarker for quick, sometimes dramatic, and durable response to immunotherapy as seen in the first line studies (CheckMate 142, KEYNOT...
What factors would make you choose IPI3/NIVO1 frontline for advanced unresectable and metastatic HCC based on CheckMate 9DW?
Great question! CheckMate 9DW with the combination IPI3/NIVO1 compared to sorafenib/lenvatinib (85% were lenvatinib in the control arm) significantly improved OS (23.7 months vs 20.6 months, HR 0.79, P-value 0.018), response 36% vs 13% (P-value <0.0001). Based on these data, it received FDA approval...
How does your management of stomatitis from Dato-DXd compare to your approach for stomatitis from other cancer-directed treatments?
By and large, the treatment is similar, though dexamethasone rinses are essential (10 mL oral solution, 4 times a day). Patients should swish/gargle the steroid solution for 1-2 minutes, then spit it out. Food and drink should be avoided for 30 minutes afterward. Similarly, patients should avoid cau...
For patients with newly diagnosed unmutated CLL how will you decide between BTKi alone vs Ven/BTKi vs Ven/Obin vs Ven/Obin/Acalabrutinib?
My usual practice has been Ven Obin for most patients, even unmutated, but if they have bulky nodes and are young/fit, I am now adding acala to that and giving the 3-drug regimen. Continuous BTKi in my practice is mostly reserved for the older or less fit patients, or those who really, really don’t ...
For patients with newly diagnosed unmutated CLL how will you decide between BTKi alone vs Ven/BTKi vs Ven/Obin vs Ven/Obin/Acalabrutinib?
My usual practice has been Ven Obin for most patients, even unmutated, but if they have bulky nodes and are young/fit, I am now adding acala to that and giving the 3-drug regimen. Continuous BTKi in my practice is mostly reserved for the older or less fit patients, or those who really, really don’t ...
How, if at all, are you employing ctDNA in the management of patients with colon cancer?
This is a great question and one that has been a huge point of extensive discussion with a lot of my patients and colleagues. I think there is a lot of variation at this time amongst providers in the implementation of this test, but I will provide my general approach and welcome other approaches as ...