Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
Knowing that spread of lobular carcinoma is often more insidious than ductal carcinoma, do you order different staging studies for lobular cancer?
No I would not stage lobular cancers differently than other histologies. There is no clear evidence that node negative lobular carcinomas are more likely to have distant metastases at initial diagnosis than other histologies. Moreover, lobular cancers are notoriously difficult to detect by imaging. ...
Do you recommend using a ctDNA assay for a patient with HER2+ metastatic breast cancer in a continued CR to guide decision about whether to stop anti therapy?
This is a good question and is not a rare situation in the management of HER2+ metastatic breast cancer. Radiographic complete response occurs with first-line treatment in 6-15% (CLEOPATRA, GIM-14, and other trials). Currently, the standard of care is to continue anti-Her2 therapy indefinitely. Howe...
Would you favor oral bisphosphonates over intravenous formulations for patients with hormone sensitive prostate cancer and androgen deprivation therapy (ADT) related osteopenia?
If kidney function is normal, either would do. Therapy depends on the risk level. (See Cosman et al., PMID 39073912.)
How do you perform surveillance on metastatic well differentiated neuroendocrine tumors?
Well differentiated NETs span the Ki67 proliferation spectrum of 0% to well above 50% and have a very variable, and at times unpredictable, history. Grade 3 well differentiated NETs are increasingly recognized. A general rule, but not perfect, is that higher Ki67 predicts more aggressive tumors. Tum...
Is it safe to continue capmatinib during palliative radiation to a bone lesion in patients with metastatic lung cancer?
This a great question, and to my knowledge, there is no good literature (prospective or retrospective) to guide the treatment decision. That said, we have anecdotal experience continuing capmatinib during palliative radiation to osseous metastases, and that is the approach I favor.
Do you screen for VWD in all women with menorrhagia severe enough to cause iron deficiency anemia?
Yes, testing vWF is needed in this situation of severe menometrorrhagia. Excessive menstrual bleeding, especially when severe enough to cause anemia, is a common presenting symptom of vWD in women. The testing should be done as part of a comprehensive workup for gynecologic etiologies and other coag...
Which neoadjuvant chemotherapy regimen would you use in a young, premenopausal woman with a rapidly growing clinical node positive poorly differentiated TNBC with a germline PALB2 mutation?
My preference is 2) weekly paclitaxel/carboplatin followed by AC, with adjuvant capecitabine if residual disease. There is no doubt that the addition of carboplatin increases the pCR rate in TNBC, and data from GeparSixto and patients on CALGB 40603 in whom doses of paclitaxel/carboplatin were not o...
What would your next line of treatment be for a patient with Hb SC with history of recurrent VOC and new bone infarct who is already on hydroxyurea and phlebotomy?
HbSC disease is the stepchild of sickle hemoglobinopathies with almost no studies of its treatment, so that any recommendation is not data based. One might consider adding crizanlizumab that blocks red cell-endothelial cell adherence. Each treatment group of the crizanlizumab study that led to its F...
Would you consider using capecitabine in a patient who previously had encephalopathy with 5-FU?
I will offer my anecdote of a patient I've treated with metastatic rectal cancer. When given FOLFIRI/bev, he felt terrible 1-2 days after the 5-FU pump started. 1st cycle, bounced back with time. 2nd cycle, went to the ER and got admitted for encephalopathy, had hyperammonemia and lactic acidosis. S...