Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How many days do you hold osimertinib during or around SBRT for oligometastatic EGFR mutated advanced lung cancer?
This a great question and a common clinical scenario that we are all confronted with. Stereotactic body radiation therapy (SBRT) is being increasingly used for oligometastatic progression of EGFR mutant NSCLC. The theoretical risk of combining EGFR inhibitors and radiation therapy would be an enhanc...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
What adjuvant chemotherapy would you recommend in an elderly patient with resected stage III colon cancer with MMR deficiency with MLH1 promoter hypermethylation?
This is a great question and actually a quite common situation we see in the clinic. Majority of the dMMR colorectal cancer is actually due to MLH1 promotor hypermethylation (about 75% of all dMMR colorectal cancer) while a small portion of dMMR colorectal cancer is due to Lynch syndrome. These pati...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
What GDMT do you recommend for patients with AL amyloidosis and systolic heart failure?
You are correct that cardiac amyloidosis patients do not tolerate most of the GDMT. SGLT2i may be helpful for both diuresis as well as HFpEF, and we do try to start this. Generally, they do not tolerate ARB/ACEI or even beta blockers. We find that torsemide seems to have better GI absorption and thu...
What adjuvant treatment would you offer a patient with adenocarcinoma of the mid-esophagus cT2N0M0 who underwent upfront esophagectomy, which showed T2N1 disease with negative margins?
Unfortunately, it's not an uncommon situation for patients to be upstaged following surgery without prior preoperative chemotherapy. This is because imaging modalities and even endoscopic ultrasound have limited sensitivity for detecting lymph node metastases.A related issue is whether patients with...
What are your top takeaways in thoracic cancers from ESMO 2025?
I think that the data regarding Sac-TMT vs. frontline platinum chemotherapy was the most impactful data. With all of the caveats of a China-only study, this is the first time that we have seen an ADC demonstrate a survival advantage in this setting. The other two presentations are less novel, but t...