Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
How do you approach patients with metastatic uveal melanoma not a candidate for tebentafusp-tebn?
I perform genomics and try to find a clinical trial that fits the patient. Including local liver therapies, such as the Delcath catheter treatment if available. Isolated liver lesion could also be resectable, so I request a surgical opinion. If nothing is available, then I offer ipilimumab/nivolumab...
What is the minimum duration to be on bicalutamide prior to starting GnRH agonist in de novo metastatic prostate cancer with significant bone disease?
The onset of action for bicalutamide is rapid--typically slightly more than a day to reach maximum/peak concentration. In contrast, the pharmacological effect of leuprolide is related to the time to testosterone suppression which occurs approximately 2-4 weeks after starting. So the time to testoste...
Why does NCCN still not recommend using circulating tumor DNA to guide adjuvant chemotherapy in stage II colon cancer when colon cancer experts are currently embracing the practice?
While I cannot speak to that panel itself, I can support the very rigorous process that all NCCN guidelines undergo, and I surmise that the reason why ctDNA is not yet recommended is because there is no consensus that: It is better than CEA and good quality cross-sectional imaging (see, for example,...
Would you use immunotherapy in patients with HIV and a positive viral load?
Current guidelines do not recommend universal HIV screening before starting immune checkpoint inhibitors (ICIs). However, if HIV is known or suspected, patients should ideally be on antiretroviral therapy (ART) before initiating immunotherapy.Safety:Retrospective data from the CATCH-IT Consortium (E...
How would you treat a patient with rectal cancer with a positive margin on resection after receiving TNT?
I'm assuming that this patient received the typical ~4 months of FOLFOX followed by capecitabine/XRT of TNT, and that by the lack of responses, this suggests this situation is quite challenging! Despite the high risk of recurrence, in someone who has had prior radiotherapy and chemotherapy, I don't ...
Do you choose to include or omit growth factor support in the treatment of Hodgkins lymphoma?
I typically do not use "up front" growth factor support unless my patient is frail. If symptomatic neutropenia develops during therapy I will add growth factor support at that time. For the patient with asymptomatic neutropenia I will continue therapy and individualize the decision for the addition ...
Do you choose to include or omit growth factor support in the treatment of Hodgkins lymphoma?
I typically do not use "up front" growth factor support unless my patient is frail. If symptomatic neutropenia develops during therapy I will add growth factor support at that time. For the patient with asymptomatic neutropenia I will continue therapy and individualize the decision for the addition ...
How do you approach a patient with high titer ANA and a new diagnosis of ITP, but no other signs or symptoms suggestive of active rheumatologic disease?
I would certainly treat the ITP with hematology involvement if necessary but would continue to monitor for lupus or similar CTDs. I have seen patients present with an ITP-like picture for years before lupus declared itself eventually. It may take years. I would also check a UA for proteinuria. This ...
Would you recommend adjuvant chemotherapy for a patient with subcentimeter pancreatic adenocarcinoma incidentally found during a Whipple resection for high risk IPMN?
Short answer is yes, I do. IPMNs with a foci of invasive carcinoma are at risk for recurrence. The prognosis is generally felt to be more favorable than with conventional PDAC, but that may be due to a higher percentage of them being found at an earlier stage. (E.g. ~25% IPMN-associated carcinomas d...