Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is switching to carboplatin/gemcitabine reasonable for a patient with muscle invasive bladder CA who proceeded to cystectomy first and had AKI with cisplatin/gemcitabine prohibiting further cisplatin?
There is not a role for gemcitabine and carboplatin in the adjuvant setting in patients with muscle invasive bladder cancer. Based on CheckMate 274 (Bajorin et al., PMID 34077643), in patients with MIBC with a high risk of recurrence (pT3, pT4a, or pN+ and not eligible for or declined adjuvant cispl...
How would you advise medical oncologists who recommend checkpoint inhibitors for a patient with baseline type 1 diabetes?
T1DM means near-complete beta-cell deficiency. These patients aren’t making enough insulin to impact blood glucose control. We always treat the cancer first, with the most appropriate medications, and worry about the diabetes later. We even advise oncologists to continue ICIs after a patient develop...
How would you treat a patient with metastatic NSCLC, adenocarcinoma subtype with BRAF V600K mutation, PD-L1 >50% with progression on 1st line chemo-immunotherapy?
Will treat with BRAFi/MEKi combination. We extrapolate data from experience in melanoma, given BRAF V600 mutation occurs much less commonly in NSCLC. BRAF V600K is another class I activating exon 15 BRAF mutation, which occurs in about 10% of all BRAF-mutated melanoma, and is associated with worse p...
How would you approach a patient with early-stage orbital MALT lymphoma with high proliferative index?
Local control for indolent lymphoma with 2 x 2 Gy is very good based on this series. Fasola et al., PMID 23726002. I am in favor of attempting 2 x 2 Gy and closely monitoring (together with an ophthalmologist) for possible recurrence, which can then be treated with full-dose RT (24-30Gy). This appro...
How would you approach a patient with early-stage orbital MALT lymphoma with high proliferative index?
Local control for indolent lymphoma with 2 x 2 Gy is very good based on this series. Fasola et al., PMID 23726002. I am in favor of attempting 2 x 2 Gy and closely monitoring (together with an ophthalmologist) for possible recurrence, which can then be treated with full-dose RT (24-30Gy). This appro...
For patients with T1 bladder cancer who have severe obstructive uropathy/hydronephrosis, do you treat as high risk stage I disease with RC, or clinically upstage and manage as a more locally advanced disease (NAC+RC)?
Clinical staging of bladder cancers with cystoscopy and imaging is associated with significant upstaging at immediate surgery nearly 25% of the time. Hydronephrosis is typically viewed as a T3 disease barring some other clear-cut cause high in the ureter such as a stone. Therefore, I prefer to have ...
Is there any evidence that ivermectin suppresses the PSA level in prostate cancer?
Is this even the right question, though? ADT drops PSA very reliably and yet does not cure patients. Finasteride suppresses PSA, but we do not use it as a mainstay of cancer treatment. Even if ivermectin *did* suppress PSA, unless there is a meaningful oncologic benefit (*at least* reduced recurrenc...
Would you switch from carboplatin/etoposide to cisplatin/etoposide in an LS-SCLC patient who initially declines cisplatin but subsequently agrees to it?
I have never seen such a clinical situation before. My simple answer would be that I would keep the carboplatin and not switch to cisplatin. That being said, I think there is more and more data that carboplatin and etoposide are pretty much equivalent to cisplatin and etoposide in LS-SCLC. There are...
When will you choose Tarlatamab over an alternative systemic therapy (e.g. lurbinectedin, topotecan) for relapsed ES SCLC?
I generally offer tarlatamab as a second line option in small cell lung cancer patients who are fit (ECOG 0-1), can logistically accommodate the hospitalization and infusion schedule, have low-risk factors for ICANS, and have treated brain metastases. I would consider a platinum etoposide rechalleng...
When do you consider testing for dihydropyrimidine dehydrogenase (DPD) for patients prior to treatment with 5-FU/capecitabine?
Happy to address this question! It is my practice to test for DPD deficiency in all patients who will receive a first treatment with a fluoropyrimidine agent (5-FU or capecitabine). My objective in doing this is to avoid infrequent but readily avoidable severe toxicities and deaths related to DPD de...