Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there a risk of increased side effects with combined radiation and ibrutinib therapy?
It is increasingly common to see patients with various hematologic malignancies requiring palliative RT who are on small molecular inhibitors (such as ibrutinib) or other novel agents. There is often a dearth of information in the medical literature regarding the safety of combining RT with these dr...
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...
How do different inflammatory markers like CRP and ferritin contribute differently, if at all, to the monitoring of CART neurotoxicity?
These markers are routinely monitored as they are seen in association with CRS (cytokine release syndrome). Not all patients with CRS will also develop neurotoxicity (ICANS), but most patients with ICANS have antecedent CRS, so in an encephalopathic patient post-CART who does not have significant el...
Which of the many possible adjuvant chemotherapy regimens do you prefer for a fully resected extraskeletal osteosarcoma?
Important to remember that EOS mimics STS more so than skeletal OS, so the STS rules apply. It is not nearly as sensitive to SOC drugs as a skeletal OS, and CDDP and MTX have very limited activity. All this said, in a very high-risk situation of systemic Rx is planned, the drugs of choice are doxoru...
What adjuvant therapy, if any, do you consider for high grade extraskeletal osteosarcomas after R0 resection?
Extraskeletal osteosarcoma is generally managed as other soft tissue sarcoma would be managed (as per NCCN guidelines for bone cancer Version 1.2019). For a high grade soft tissue sarcoma that has been removed with an R0 resection, radiotherapy should be considered depending on the location of the t...
When would you use proximal complement inhibitors like pegcetacoplan over terminal complement inhibitors for initial treatment of paroxysmal nocturnal hemoglobinuria?
I use either iptacopan or pegcetacoplan as primary therapy for PNH these days. Since its release, I have used mainly iptacopan. Its advantages are 1) it is oral, 2) the side effect profile is very tolerable, 3) it only inhibits the alternative pathway, thus is likely to be associated with less risk ...
How do you incorporate PCI into your management of patients with extensive stage SCLC?
The role of prophylactic cranial irradiation (PCI) in the modern era of brain MRI surveillance has been called into question and is the topic of the ongoing phase 3 SWOG S1827/Maverick trial of MRI surveillance +/- PCI (or hippocampal avoidance [HA]-PCI) for LS and ES-SCLC, where I serve as the prin...
When MGUS is suspected in a patient with one risk factor and no evidence of end-organ damage, what additional workup should be done, if any?
My approach applies only for the scenario of thinking about monoclonal gammopathy -> myeloma spectrum. Monoclonal gammopathy -> amyloidosis or MGRS/MGNS, etc. I think of quite differently.Our VA pathways and other organizations have advocated for bone marrow biopsy in this situation. For example, in...
How do CheckMate 8HW results impact your sequencing of available therapies in dMMR/MSI-H metastatic colorectal cancer?
The results of CheckMate 8HW further reinforce the use of immunotherapy over chemotherapy for dMMR/MSI-H metastatic colorectal cancer. In 2025, in my practice, assuming a patient has no contraindications to immunotherapy, I see no role for chemotherapy in 1st line metastatic colorectal cancer that i...
Are there long-term toxicity and QOL considerations for patients receiving nivo/ipi compared to checkpoint monotherapy that would impact your treatment decisions for first line metastatic MSI-H/dMMR CRC?
Ipi/nivo is much more toxic than single agent checkpoint inhibition with serious autoimmune-type side effects like "Triple M" Overlap Syndrome, myocarditis, pneumonitis, and hepatitis, and I would lean away from ipi/nivo for frail patients or older adults who are not robust. I think a careful geriat...