Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you modify the hemoglobin goal and ESA dosing for patients with sickle cell anemia and ESKD on hemodialysis?
In sickle cell patients, I coordinate care with the patient's hematologist. I will reduce the hemoglobin goal to 8-10 g/dl, and if patients have a history of crises, closer to 10 g/dl, I may choose 7-9 g/dl. ESA requirements seem to be higher in sickle cell patients, so I would start with 100 units/...
Would you consider bevacizumab for a patient with SCLC who has asymptomatic brain metastasis progression after CNS radiation while on maintenance immunotherapy?
I am assuming SCLC is small cell. I wouldn't do it now that we have agents such as tarlatamab, which has better CNS penetrance. Adding bevacizumab to atezo does have a rationale and theoretical benefit. The CeLEBrATE study, which was recently published, showed synergy between chemo, atezo, and bev, ...
For AYA patients with early-stage Hodgkin's lymphoma being treated with ABVD, how many cycles of chemotherapy do you administer, and when can radiation be avoided?
It depends - favorable/unfavorable, distribution of disease, co-morbidities, gender, family history, etc. I don't treat pediatric patients, so the comment below applies strictly to young adults.If a patient has early-stage, favorable HL per GHSG criteria (no risk factors), then 2 cycles of ABVD + 20...
What is the optimal duration of therapy in patients with metastatic colon cancer with no evidence of disease?
First of all, it sounds as if congratulations are in order for your management (to have sustained a patient with mCRC for over 5 years is truly a remarkable accomplishment, although in cases like this the self-pitying oncologist might wonder if they are victims of their own success in determining a ...
Is there a threshold absolute neutrophil count for which you would consider holding radiation?
I don't have a threshold dose for holding radiation. This decision is based on the etiology of the leukopenia. If the patient is receiving concurrent chemoradiotherapy it is usually the chemotherapy causing the issue and I rarely hold radiation even with ANC < 1000. If one were to hold both the chem...
What factors do you consider when you are deciding whether to recommend endocrine therapy for a woman who has had a mastectomy for DCIS for contralateral breast cancer risk reduction?
Endocrine therapy after a mastectomy for DCIS is primary prevention, and therefore elective. I present this as an option to decrease contralateral breast cancer risk. I quote that risk as approximately 0.7% chance per year. I generally don't recommend it for older patients or to patients with HR-neg...
What adjuvant therapy would you recommend for a cisplatin and IO ineligible patient with node positive urothelial carcinoma with mixed histology?
This is a difficult situation and I agree that there is evidence for adjuvant carboplatin-gemcitabine in cisplatin-ineligible patients with high-risk upper tract urothelial carcinoma, although benefit appeared more modest compared to cisplatin-gemcitabine (POUT trial). It is reasonable to extrapolat...
What first line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
Yes, it is safe, but I always treat the CNS metastasis first (e.g. SRS). The risk of bleeding in an untreated CNS metastasis with a VEGF TKI is otherwise unacceptable in my opinion. The edema should be treated with steroids as appropriate and I haven't experienced TKIs worsening CNS edema.
Do you treat muscle-invasive urothelial bladder cancer with plasmacytoid features any differently in terms of the recommendation for neoadjuvant cisplatin-based chemotherapy?
Plasmacytoid variant carcinoma is a rare aggressive variant that tends to be chemosensitive but recurs frequently and is characterized by CDH1 loss of function genomic alterations and peritoneal metastasis. In predominant plasmacytoid urothelial carcinoma, the role of neoadjuvant chemotherapy (NAC) ...
How do you decide between radioligand therapy or cytotoxic chemotherapy in patients with metastatic castration-resistant prostate cancer with prior ARPI exposure who have cancer-related anemia?
Radioligand therapy (presumably the question refers to Lu-177 vipivotide tetraxaten/Pluvicto) is one of the latest and most promising treatments for mCRPC. As in all cancer treatments, the practitioner needs to have a good understanding of adverse event likelihood, but also the potential for benefit...