Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
How do you choose a neoadjuvant therapy regimen for a patient with a triple negative breast cancer and a synchronous ER-/Her2+ breast cancer?
Assuming there is no contraindication to administration of an anthracycline, I would favor weekly paclitaxel and weekly carboplatin with every 3 week trastuzumab and pertuzumab x 12 weeks followed by ddAC x 4. This gives the TNBC the benefit of the higher pCR rate seen with the addition of carboplat...
Would you consider enfortumab vedotin + pembrolizumab prior to surgery for a patient with urothelial carcinoma with regional nodes who is not eligible for neoadjuvant cisplatin?
The appropriate management for LN+ bladder cancer is not clear, and whether or not to use EV+pembrolizumab in this setting is also without significant data. Clinically and practically, there are so many gray areas in this question that the best path is at best charcoal-colored. Generally, systemic t...
How would you treat a young premenopausal female with triple negative inflammatory breast cancer who progressed on carboplatin/paclitaxel/pembrolizumab (KEYNOTE 522), but didn't receive anthracycline portion and has a positive BRCA2 mutation?
I assume she had surgery already given progression. I would proceed with AC/pembro, and subsequently would continue pembro with the addition of olaparib. Given her BRCA2 mutation, she would not be eligible for Optimice-RD.
What is your preferred method of surveillance after mastectomy?
The answer depends on clinical circumstances. For all the details, I refer you to NCCN guidelines where this is discussed specifically. However, let me summarize a few key points. Patients are usually seen several times a year for 5 years, less often thereafter. A history and physical exam is always...
Would you consider a positive DAT and indirect Coombs test, persistent and consistent with IgG warm antibody, clinically significant in absence of hemolysis?
Up to half of patients with red cell auto-antibodies (i.e., true positive DAT/direct Coombs test) are not experiencing hemolysis. After iron repletion in this patient, the best way to determine the degree of hemolysis and whether treatment is needed is by the stability of the hemoglobin and the reti...
Would you consider a positive DAT and indirect Coombs test, persistent and consistent with IgG warm antibody, clinically significant in absence of hemolysis?
Up to half of patients with red cell auto-antibodies (i.e., true positive DAT/direct Coombs test) are not experiencing hemolysis. After iron repletion in this patient, the best way to determine the degree of hemolysis and whether treatment is needed is by the stability of the hemoglobin and the reti...
How would you approach de novo metastatic castrate sensitive prostate cancer with extensive locoregional spread causing rectal compression, retroperitoneal lymphadenopathy, and PSA >3000 but no visceral or bone metastases?
It sounds like from the question that the patient has T4 disease invading the rectum. This makes the patient ineligible for surgical resection with curative intent. He might still be a candidate for curative intent radiation therapy/ADT +/- abiraterone per STAMPEDE. His highly elevated PSA is very w...
Will you offer adjuvant nivolumab for high-risk muscle invasive bladder cancer based on results of CheckMate 274?
CheckMate 274 met the co-primary endpoints of statistically significant improvements of DFS in all-comers (HR 0.70) and the PD-L1+ (HR 0.53) populations. These endpoints were presumably chosen by the investigators in discussion with the FDA for a registration trial like this, given that improved DFS...