Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are the recommended prophylactic measures for managing or mitigating diarrhea when pertuzumab is combined with trastuzumab deruxtecan, given toxicity risk with each individually?
My understanding is that prophylactic anti-diarrheals were not required in the trial but left to institutional discretion. While the rate of diarrhea in DB-09 was 56%, most of these were Grade 1-2 (only 7% were Grade 3 or higher). As such, I am not starting antidiarrheals prophylactically, but I do ...
Are there any data regarding safety or efficacy of osimertinib and concurrent chemotherapy in patients with metastatic NSCLC harboring sensitizing EGFR mutation?
The OPAL study evaluated 1st-line osimertinib combined with platinum-pemetrexed in 67 patients with EGFR-mutated NSCLC in Japan (Saito et al., PMID 36966696). The combination yielded an objective response rate of 90.9% (95% confidence interval, 84.0-97.8), with a median PFS of 31.0 months (95% CI, 2...
For a patient with metastatic melanoma with small, asymptomatic brain mets what is your preferred systemic therapy?
In this scenario, I default to using a combination of ipilimumab plus nivolumab. We know from prior clinical trials that have looked at this combination of patients with asymptomatic brain metastases that immunotherapy seems to work similarly well intracranially as it does extracranially. This was e...
When using T-DXd/pertuzumab regimen in frontline treatment of HER2+ metastatic breast cancer, are you adapting the regimen with induction and then de-escalation to maintenance?
Outside of a clinical trial, I do not routinely define a fixed induction-and-maintenance strategy when starting T-DXd with pertuzumab. Instead, I individualize treatment over time based on response, tolerability, and patient priorities. While many patients achieve deep and durable responses, cumulat...
What criteria would you consider to select patients for 20 Gy consolidative RT in DLBCL/HGBL?
The primary endpoint of the study was 5-year local control. The study was powered to estimate this endpoint after the last patient had at least 2 years of potential follow-up (which will be reported at ASTRO). Local failures after 2 years are uncommon. The estimated 5-year freedom from local recurre...
When making treatment decisions, how do you deal with conflicting results on HER2 measurement via IHC, FISH, and Oncotype Dx HER2 expression levels?
IHC and FISH are the standard-of-care assays for HER2 status determination, and treatment decisions should be based on IHC/FISH results rather than Oncotype DX HER2 mRNA expression levels when discordance exists (Tozbikian and Zynger, PMID 29498449; Neely et al., PMID 30230095). The Oncotype DX HER2...
Would you consider proceeding with a sentinel lymph node biopsy after wide excision revealed 1.2 mm residual non-ulcerated T2a melanoma on the upper back?
Any melanoma with Breslow’s depth of more than 0.8 mm (more than T1a) needs a sentinel lymph node biopsy for complete staging, due to higher chance of lymph node metastasis. Ideally, it should be done at the time of wide local excision, as doing the sentinel lymph node biopsy afterwards may be more ...
How should medical oncologists and dermatologists communicate about patients with at least Stage IIB/III cutaneous melanoma regarding neoadjuvant immunotherapy?
Only melanoma patients with stage III or resectable stage IV disease should be treated with standard-of-care neoadjuvant immunotherapy. These patients should see a medical oncologist first (and no longer last, as is the current process). I would recommend that the schedulers at your institution be e...
What whole brain radiation dose would you recommend for primary CNS lymphoma with partial response to HD-MTX-R and R-ICE and planned for concurrent ibrutinib?
There are many uncertainties in how to optimal treat patients with PCNSL. It is clear that high-dose MTX-based regimens should be pursued when feasible. The role, if any, of RT is controversial. If pursued, a WBRT-based approach is generally considered most appropriate.With that said, if a patient o...
Do you see a role for ultra-low-dose immunotherapy in your patients with relapsed or refractory solid tumors, and if so, in which clinical scenarios?
To date, there is not enough definitive data to support the use of low-dose immunotherapy. Moreover, ultra-low-dose nivolumab (20 mg Q2W or Q3W) has phase III evidence demonstrating an OS advantage over salvage chemotherapy in pretreated solid tumors, with a favorable toxicity and QoL profile. Its s...