Clinic Notes: Oncology 2.0

People are often surprised when I tell them I rarely prescribe traditional chemotherapy anymore.

It’s not because it doesn’t have a role. Chemotherapy still saves lives and remains essential in many cancers. But for a growing number of patients, we now have better options. These are treatments that are more targeted, more personalized, and often less toxic.

I specialize in melanoma and early-phase clinical research, and I haven’t prescribed chemotherapy for melanoma in years. Instead, I offer immunotherapy, targeted therapy, and clinical trials with promising approaches like bispecific T-cell engagers (BiTEs) and tumor-infiltrating lymphocytes (TILs). These therapies are designed to work with the immune system or go after specific cancer targets. We’ve made real progress, though there is still more work to do.

This shift is happening across oncology.

Here are ten cancers where chemotherapy is used less often, replaced by more effective or better-tolerated treatments:

1. Melanoma Immunotherapy and targeted treatments are now the primary tools. Chemotherapy is rarely used.

2. Chronic Myeloid Leukemia (CML) Oral tyrosine kinase inhibitors like imatinib allow most patients to live normal lifespans without chemotherapy.

3. Chronic Lymphocytic Leukemia (CLL) Targeted drugs like venetoclax and BTK inhibitors are commonly used first-line. Chemotherapy is now the exception.

4. MSI-High Colorectal and Endometrial Cancers Immunotherapy can provide long-lasting responses for patients with mismatch repair deficiency.

5. ER+ Breast Cancer (Low Oncotype DX Score) Hormonal therapy alone is often appropriate when genomic testing shows a low recurrence risk.

6. PD-L1 High Non-Small Cell Lung Cancer Single-agent immunotherapy may be more effective and better tolerated than chemotherapy in selected patients.

7. Advanced Prostate Cancer Hormone-targeting agents like enzalutamide and abiraterone are now preferred over chemotherapy in many cases.

8. Kidney Cancer Most patients now receive immunotherapy and VEGF inhibitors, not chemotherapy.

9. Liver Cancer (HCC) The combination of atezolizumab and bevacizumab has become a standard first-line treatment.

10. Multiple Myeloma Treatment now often starts with monoclonal antibodies and other targeted agents, reducing the need for traditional chemotherapy.

We still rely on chemotherapy when the evidence supports it, particularly when it improves cure rates. But in many cases, we are moving toward more refined treatment strategies.

As an oncologist, it’s meaningful to be able to offer patients better options. And when a clinical trial is available that could replace chemotherapy with something more precise or less toxic, I do my best to make that available.