Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a young breast cancer patient with limited nodal involvement and an isolated sternal oligometastasis at diagnosis?
Although there is limited data to support this approach, I have treated similar patients with "curative intent" with respect to the RT portion of their treatment. If the sternal oligomet is in close proximity to the ipsilateral IMNs, it can be included within the partial wide tangent fields for the ...
Can the results of Checkmate 577 be applied to patients who do not undergo surgery following chemoradiation because of a clinical complete response?
The standard approach for patients with locally advanced esophageal cancer would be to proceed with surgical resection after neoadjuvant chemoradiation, regardless of clinical response. And then, if surgical pathology confirms residual disease, to proceed with adjuvant nivolumab. If the clinical res...
Would you consider perioperative antifibrinolytics for mild factor 7 deficiency undergoing surgery?
I do use antifibrinolytics in factor VII deficiency; however, it depends on the specifics of the surgery (i.e., mucosal surface surgery, sequelae of bleeding should it occur - spine vs oral), the patient's bleeding history, and the factor VII level. Here, I wonder if the original diagnosis was corre...
Can aplastic anemia present with multiple infiltrative bone lesions, such as in the spine and pelvis?
There are several studies showing diffuse hypointense pictures with an infiltrative-like pattern on MRI in aplastic anemia and MDS. Some aplastic anemia and refractory cytopenia of childhood show patchy pattern of hematopoiesis with some regions having increased fat fraction and some remnants of hem...
Do you modify dosing and monitoring of Lu-177–PSMA therapy for patients with prior large-field RT involving substantial active marrow compared with patients who only had focal bone SBRT?
No, we do not modify dosing and monitoring of PSMA therapy with prior large-field RT. In the VISION trial, the vast majority of patients were heavily pre-treated, presumably many with pelvic radiation for definitive treatment or treatment for bCR prior to metastasis. Assuming that the patient had ap...
How does one interpret the LUMINA trial in the FLORENCE APBI ERA?
This is a common scenario. My practice is to discuss this with the patient. I discuss 5 fraction PBI or 5 fraction WBI depending on the scenario, as well as endocrine therapy and the differences in toxicity profiles. Given compliance rates of 50-60% with endocrine therapy long-term, many patients pr...
Despite the paucity of strong data showing benefit of chemotherapy + radiotherapy in patients with stage I-II high risk histology endometrial cancer, if you recommend treatment with both modalities, how do you determine treatment schedule?
For the purpose of this answer, I'll define high risk as serous, carcinosarcoma, undifferentiated, and dedifferentiated. Clear cell carcinoma can be considered and likely treated more by its molecular profile. As you indicate, there is little data to support the routine use of chemotherapy for FIGO ...
How would you manage a patient with DLBCL that progressed on/after EPOCH and subsequently treated with a CD19 allo CAR-T product within 90 days of receiving apheresis?
I'm sorry, but the question is unclear. Did his disease progress after CD19 allo CAR-T? If so, I would offer commercially FDA-approved CD19 CAR-T. The fact that his disease progressed quickly after allo CAR-T is possibly due to a lack of expansion and long-term persistence, which can be mitigated by...
In what scenarios do you use a chromogenic factor X assay in adjusting INR goals for patients on warfarin?
I do not use this method. It has been suggested that such assays be used in patients with lupus-type inhibitors who have significantly prolonged prothrombin times at baseline. In this setting, if the INR is "therapeutic," one would confirm an adequate warfarin effect if the factor X activity was in ...
In the current era of adjuvant CDK4/6 inhibitor use for high-risk HR+/HER2-negative breast cancer, what is the preferred adjuvant chemotherapy regimen for premenopausal women — AC-T or TC?
In premenopausal women with genuinely high-risk HR+/HER2- disease (MonarchE and some NATALEE groups, especially Stage III), I believe there remains a role for dose-dense AC/T as the adjuvant chemotherapy backbone. Data from EBCTCG do portray a 2.5–2.6% 10-year recurrence and 1.6% 10-year breast canc...