Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with a recent diagnosis of advanced DLBCL (non-GCB subtype) who has baseline grade 3 neuropathy?
Avoid neurotoxic agents. Substitute pola; avoid vincristine.
How would you manage a frail patient with GCB DLBCL who is unable to complete R-CHOP but has moderate residual disease?
We need a little more information to answer this question. First, what was the stage at diagnosis? Why is the patient frail - is this disease related, or is this a result of therapy? The age of the patient can also assist in making this decision. Also, what is the moderate disease? Can this be inclu...
Would you add immunotherapy to chemotherapy for a patient with metastatic NSCLC, an atypical EGFR mutation, and PD-L1 ≥50% who has progressed on osimertinib?
This is a difficult scenario, and there is no data to guide this. There is good evidence to suggest that patients with the classical mutations do not respond to ICIs regardless of PD-L1 expression. There is one small retrospective analysis that included 7 patients with uncommon mutations (G719X and ...
Is there evidence to support bladder preservation therapy in node positive bladder cancer?
Although there aren’t randomized data suggesting the superiority of trimodality therapy (TMT) over any other treatment for N+ bladder cancer, I think most feel that it is the standard of care as alluded to in the question. Broadly speaking, patients and providers have two options: radical therapy or...
How do you decide between maintenance avelumab vs CRT for patients with N2-3 bladder cancer who have SD or PR after platinum induction?
For patients with N2-N3 disease who have a clinical PR or SD with platinum-based chemotherapy, switch maintenance avelumab would be quite reasonable since such patients were eligible for the JAVELIN Bladder-100 phase III trial (and benefit was seen regardless of PD-L1 status, although benefit appear...
What would you offer for a very young patient with metastatic renal medullary carcinoma who has progressed on cisplatin-based chemotherapy?
Doxorubicin-based regimens (per our study here) adapted to context and EGFR-targeted therapies (see here, but do not use bevacizumab as discussed here and here) with prioritization for panitumumab-based therapy as discussed here (from 5:00 onwards) and in yesterday's IKCS: NA session on rare kidney ...
When do you refer a patient with recurrent glioma for reoperation?
This question is a nuanced one that is dependent on many factors. When a patient has a recurrent glioma, the treatment options are generally re-resection, medical therapy (traditional chemotherapy or targeted agents, depending on the tumor), or radiation. Which treatment modality, or combination of ...
In addition to monitoring hemoglobin and supplementing folic acid, what is your approach to hereditary spherocytosis in pregnancy?
I use the same transfusion threshold for the general pregnant population but I do refer to maternofetal medicine/high risk pregnancy clinic for closer fetal monitoring. My personal preference is to obtain genetic testing to confirm the specific mutation responsible for hereditary spherocytosis as it...
What vitamins and minerals do you check yearly for patients post gastric bypass surgery?
Following Roux-en-Y gastric bypass it is essential to monitor micronutrients, vitamins, and minerals because malabsorption and long-term complications may occur with improper care. Based on ASMBS 2016 Nutrition Guidelines, AACE/TOS/ASMBS 2019 updates, and Endocrine Society recommendations, here are ...
How do you manage B12 deficiency refractory to subcutaneous replacement?
I tend to start with IM injections of B12 when patients are severely deficient. The most common mistake in replacing severely low B12 is to not load, or to check levels too early. I have not used SQ administration before. It should absorb, but if you are having issues I would go to IM and start week...