Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach a poorly differentiated neuroendocrine carcinoma of the stomach with small cell morphology without any evidence of peritoneal or distant spread?
High grade neuroendocrine carcinoma (HG-NEC) is extremely sensitive to chemo-radiotherapy. Unfortunately, they often relapse/reoccur despite treatment with curative intent for early stage disease. In my practice, I would avoid surgery for the given clinical scenario and proceed with chemo-radiothera...
How do you manage glioblastoma presenting with leptomeningeal dissemination?
Hospice is a very legitimate option. As physicians, we recommend this far too infrequently.
What is your preferred adjuvant systemic treatment for resected stage IV melanoma with a BRAF mutation?
I agree with @Dr. First Last and prefer single-agent anti-PD1 therapy for adjuvant setting as well, given better tolerance and preserved QoL for most patients. I use targeted therapy in contraindications to ICI therapy, or prior exposure to ICI, and now with resected NED setting.
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
What is the current role of ctDNA in guiding the selection of adjuvant treatment for stage II-IIIA melanoma?
There are only retrospective, not prospective data on Natera’s tumor-informed ctDNA platform (Signatera). I would be cautious in using the ctDNA result for clinical decision-making. The gold standard is still the radiographic imaging - there is no test that will replace being able to see a measurabl...
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...
Would you favor PCI or CABG for younger patients with radiation-associated cardiac disease in the absence of any significant valvular abnormalities?
Despite the fact that the common and most serious radiation-induced coronary stenosis (RICS) are ostial lesions of the left main and ostial RCA, we heavily favor PCI when feasible due to fibrotic mediastinal changes causing significant technical challenges during CABG. Restenosis is another challeng...
In which scenarios do you stage breast cancer using CT and nuclear bone scans versus PET-CT?
In a recent study (Dayes et al., PMID 37235845), systemic staging with FDG PET-CT more frequently changed the clinical stage from IIB or III breast cancer to stage IV disease (23% metastases detection rate) than staging with CTs of the chest, abdomen, pelvis, and a bone scan combined (11% metastases...
Would you consider hormone replacement therapy in young women with germline BRCA1 mutation and history of triple negative breast cancer who underwent bilateral mastectomy and prophylactic bilateral salpingo-oophorectomy?
There is inadequate data to clearly answer the question of safety of HRT after a diagnosis of breast cancer. A recent review by Ugras and Rahman summarized the published literature and concluded that the evidence does not suggest an increase in recurrence or death with the use of HRT in this setting...
How do you approach treatment of patients with metastatic HR+ breast cancer with detection of ESR1 mutation after initiation of an AI and CDK4/6 Inhibitor?
In PADA-1 (SABCS 2021), the development of an ESR1 mutation, regardless of progression on scans, followed by the continuation of palbociclib but changing to fulvestrant, was associated with a PFS of 11.9 m. If one waited until clinical progression, then treated with fulvestrant and palbociclib, the ...