Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat patient with a stage IV lung adenocarcinoma, an exon 21 p.H835L mutation, high TMB, and negative PD-L1?
EGFR H835L mutation is a rare variant that is in Ex21 of EGFR. Though there is not a lot of data with this particular mutation, the available data suggest that it is a sensitizing mutation with a few case reports suggesting that patients harboring these mutations have a good outcome with EGFR TKI. 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 ...
How would you manage symptomatic superficial vein thrombosis during pregnancy?
The best evidence for the treatment of SVT comes from the CALISTO trial, which endorsed a prophylactic dose of fondaparinux as the treatment of choice. However, the CALISTO trial excluded pregnant women. Because data on the use of fondaparinux in pregnancy remain limited, with some traces of fondapa...
For patients undergoing bladder preservation therapy with trimodal therapy, how do you manage the urinary urgency and frequency during and after treatment?
This can be a difficult problem to manage because I try to avoid treatment interruption if at all possible, which is different from my approach in patients with prostate cancer, where treatment interruption is a safe and effective alternative. In patients with bladder cancer, the first thing I will ...
How long would you recommend a woman with HR+ node-positive breast cancer treated with surgery and chemotherapy during pregnancy can breastfeed, prior to starting adjuvant endocrine therapy?
I agree. This is unfortunately, an area with a lack of data, though in my experience, most women who are treated for breast cancer during pregnancy are still in the middle of therapy (systemic or local) after delivery, so we typically recommend against breastfeeding to avoid delays, particularly wit...
What are your top takeaways from ESMO 2023?
Lung Cancer New first line therapy for advanced EGFR Exon 20 NSCLC patients: The PAPILLION trial [Zhou et al., PMID 37870976] was a Phase 3 clinical trial among patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC) with documented epidermal growth factor receptor (EGFR) ex...
Are there data to support full-dose anticoagulation added to an antiplatelet in recurrent peripheral arterial thrombosis requiring revascularization and stenting?
This question comes up frequently at our institution. I previously consulted with our vascular surgery team who referred me to this trial of Edoxaban with SAPT, trying to avert what may be limb loss if the bypass graft/stent fails. We've often promoted rivaroxaban 2.5 mg po BID per VOYAGER PAD if we...
What are the main practical factors to consider when using bispecific antibody therapy (Tarlatamab) for extensive-stage small cell lung cancer?
The overall survival (OS) for patients with relapsed refractory small cell lung cancer is poor with an estimated OS of 8-9 months. Prior to DLL3 bispecifics, the 2nd line therapeutic options included topotecan and lurbinectidin. Topotecan always had an unusual positioning as a second line agent. The...
If a patient diagnosed with seminoma after orchiectomy has margin positive disease noted in the spermatic cord and no overt metastasis on imaging and normal tumor markers, how should this patient be staged?
I believe that the staging would be pT3cN0M0S0 in this case. Margin-positive disease suggests continuous rather than discontinuous spermatic cord invasion. In case this was felt to be discontinuous, NCCN v1.2024 now has a note on staging such patients as pT3 (high-risk stage I) and not as M1 (stage ...
In a patient with borderline resectable pancreatic adenocarcinoma who received neoadjuvant FOLFIRINOX followed by resection that demonstrated residual disease, how do you proceed in the adjuvant setting?
In order to answer this question completely, I would need to know more about the neoadjuvant FOLFIRINOX that was given. In a patient who received a full 6 months of neoadjuvant therapy followed by successful surgical resection (albeit with poor response), I would not recommend continuing systemic th...