Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider prophylactic anticoagulation for May-Thurner syndrome in pregnancy if prior endovascular intervention has been completed?
In general, I have a very low threshold to initiate prophylactic anticoagulation in pregnancy. For a patient with a history of May-Thurner that has been endovascularly corrected and who has been maintained off of anticoagulation without issue, I would have a risk-benefit discussion about prophylacti...
Can ctDNA be used to evaluate response to checkpoint inhibitors in NSCLC when pseudoprogression is suspected on CT imaging?
This is a scenario where ctDNA may have value in the future, as imaging alone is often not sufficient to reliably differentiate between pseudo-progression and true progression in patients receiving immune checkpoint inhibitors. A small study of 28 patients with melanoma suggested that ctDNA obtained...
How would you approach a patient with HR+, HER2- metastatic breast cancer who is endocrine resistant, with bone marrow involvement and pancytopenia?
Symptomatic bone marrow involvement (bone marrow carcinomatosis) is extremely rare in metastatic breast cancer and carries very poor prognosis. It is often associated with microangiopathic hemolytic anemia and DIC. Anemia is the most common manifestation and WBC and platelet counts are often not tha...
How do you manage a muscle-invasive bladder cancer patient who received neoadjuvant cisplatin-based chemotherapy but has a positive margin post-operatively?
While no trial has tested adjuvant RT plus nivolumab in margin-positive post-cystectomy bladder cancer, and this remains an extrapolation, I would consider adjuvant pelvic RT as radiation alone (cystectomy bed/pelvic nodes 45–50.4 Gy, boost the involved margin to 54–60 Gy), consistent with how NCCN ...
Would you consider use of PARP inhibitors in patients with metastatic breast cancer with moderate penetrance germline mutations such as CHEK2, ATM, RAD51?
In the Olaparib Expanded (TBCRC 048) study published by @Dr. First Last in JCO, there were no responses to olaparib in metastatic breast cancer with germline or somatic CHEK2 or ATM pathogenic variants (mutations). In contrast, responses were seen in metastatic breast cancer with PALB2 pathogenic va...
Do you use MRD testing to guide maintenance therapy discontinuation in newly diagnosed non-high risk myeloma patients?
Major bias, incoming!The short answer is: yes, I use MRD to guide de-escalation and ultimately discontinuation in standard-risk patients with myeloma.Much of that sentiment comes from our work at the University of Chicago called MRD2STOP, where we allow patients to stop treatment if they are sustain...
How will the LORETTA and COMET trials influence your treatment of low-risk DCIS?
Clearly, postop RT can be avoided, but the pink elephant in the room is, can 5 years of endocrine therapy likewise be avoided? Treatment de-intensification requires addressing all aspects of therapy, particularly if one argues against adjuvant therapies for reasons of cost and toxicity. I can't reca...
How do you manage a symptomatic primary breast tumor in a patient with metastatic disease?
It’s much harder to treat patients palliatively than to cure. The art of palliation generally requires weighing the acute and subacute toxicities of alternative treatments much more heavily and chronic toxicities less than we do for potentially curative care. It also requires assessing whether patie...
In patients with T790M mutation and progression of disease on osimertinib, is there any utility in checking peripheral blood cDNA for continued presence or absence of the T790M mutation?
We strongly believe that there is utility in sending liquid biopsy for T790M positive patients progressing on osimertinib for several reasons. One reason is that there are now identifiable resistance mutations like C797S that may emerge. Depending on their allelic relationship to T790M (cis- versus ...
Which calculators, nomograms, or other resources, if any, do you use to help advise and prognosticate patients with newly diagnosed glioblastoma or other gliomas?
This is a rather difficult question to answer because prognosis in patients with glioblastoma (GBM) is best estimated by combining several clinical, molecular, radiographic, and treatment-related factors rather than relying on any single variable. Several validated prognostic models exist, but in cl...