Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
What is optimal endocrine therapy in a young, premenopausal women with ER/PR positive oligometastic breast cancer successfully treated with curative intent neoadjuvant chemo followed by surgery+RT to skeletal oligomet?
These cases are always important to understand what discussions were had up front with the patient and all members of the team regarding goals of care. It seems the patient was treated with "curative" intent; however, the likelihood that she has actually been cured of her disease is extremely low an...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
In patients with cancer of unknown primary, do you routinely send molecular testing to help determine primary tumor origin?
The NCCN designates tumor sequencing and use of gene signature profiling as a category 3 recommendation. This is more or less consistent with NIH and ESMO guidelines in that that the impact on patient outcome remains questionable and unproven.There are multiple commercial assays in this space. The p...
Would you use routine PET scans after two cycles of R-CHOP to guide first-line treatment de-escalation in low-risk (aaIPI = 0) DLBCL patients?
This phase III trial suggests that in very low-risk limited-stage DLBCL (aaIPI = 0), patients who achieve a negative PET after two cycles of R-CHOP can safely receive only four total cycles instead of six, with similar 3-year PFS (92% vs 89%) and less toxicity. However, the results apply to a highly...
Would you use routine PET scans after two cycles of R-CHOP to guide first-line treatment de-escalation in low-risk (aaIPI = 0) DLBCL patients?
This phase III trial suggests that in very low-risk limited-stage DLBCL (aaIPI = 0), patients who achieve a negative PET after two cycles of R-CHOP can safely receive only four total cycles instead of six, with similar 3-year PFS (92% vs 89%) and less toxicity. However, the results apply to a highly...
When do you order genetic studies such as comparative genomic hybridization for melanocytic lesions?
In my practice, I confine copy number alteration studies (SNP array testing) for cases where the biological potential of a melanocytic proliferation is in question. I do not perform the testing if the case is diagnostic histopathologically and/or immunohistochemically of a nevus or melanoma.The seco...
How do you approach relapsed idiopathic HLH?
This question is quite non-specific - the answer depends very much on the specific context (child, adult, relapsed after what treatment?) and as such, can only be answered in broad strokes.First, ensure that it is truly idiopathic – check EBV, CMV viral loads, and other viral/infectious triggers as ...