Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach the treatment of teen patients with recurrent mediastinal germ cell tumor who have failed standard therapy, radiation, and HD therapy/stem cell rescue?
The query failed to delineate whether this was seminoma or non-seminoma, but probably does not matter in this advanced stage of a heavily treated patient. Also failed to address the anatomical location of active cancer. Whether this is a teen or older patient is irrelevant. For mediastinal seminoma,...
Would you consider IV thrombolytics in patients with acute ischemic stroke, with or without a large vessel occlusion, if they have a history of von Willebrand disease (VWD), regardless of its type?
I would still consider it unless the INR >1.7 or they are on anticoagulation for some clinical reason.
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
How would you manage symptomatic, bilateral subsegmental PE developed after long air travel?
I generally consider air travel to be a relatively weak provoking factor. Although the 2020 ASH guidelines do not address this, the ASH Guidelines from 2018 on management of VTE cite a 2.8-fold increased risk for VTE associated with air travel, which is roughly similar to the increased risk associat...
How would you respond to a patient with early-stage resectable NSCLC who has a clinical complete response to neoadjuvant chemo-IO, but subsequently declines surgery, not feeling it's necessary anymore?
This is an unusual scenario to have a complete response by both CT and PET criteria together. I generally counsel patients regarding false-negative and false-positive error rates of the PET scan of approximately 10-15%. With regard to CT, slice selection may also miss residual millimeter-sized disea...
Does a very high Oncotype score influence your approach to adjuvant treatment in a patient with ER positive breast cancer?
This is a very intriguing question that has a simple answer. There is no data on choice or aggressiveness of chemotherapy and resulting benefit in patients with higher oncotype recurrence score. What regimen to use remains a judgement call, but for most patients with ER+/node negative tumors with a ...
Do you recommend self-breast exams to your patients with history of breast cancer in addition to imaging surveillance?
This is a somewhat controversial question. I cannot find any data on the risks or benefits of counseling on self-exams in breast cancer survivors. I will simply say this. Among survivors, there are differences between patients that I think the physician must understand and meet the patients where th...
How do you treat patients with T-cell ALL/T-cell lymphoblastic lymphoma who have pre-existing CKD with a CrCl of 30 mL/min or less?
In our experience, it requires very close coordination with our clinical pharmacists to ensure proper dose adjustments are made. By doing this, you will hopefully deliver comparable dose intensity without increased toxicity. This assumes you achieve the same level of drug exposure for the agents tha...
How do you treat patients with T-cell ALL/T-cell lymphoblastic lymphoma who have pre-existing CKD with a CrCl of 30 mL/min or less?
In our experience, it requires very close coordination with our clinical pharmacists to ensure proper dose adjustments are made. By doing this, you will hopefully deliver comparable dose intensity without increased toxicity. This assumes you achieve the same level of drug exposure for the agents tha...
If a pregnant patient with a mechanical heart valve takes warfarin throughout her pregnancy, what are the chances that the fetus will be harmed?
Warfarin is effective for thromboembolic prevention in pregnant patients with mechanical valves. There is however an overwhelming evidence that warfarin taken during pregnancy is deleterious to the fetus. Its use during the first 6–12 weeks of gestation can be associated with important fetal complic...