Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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 ...
What chemotherapy regimen would you offer to a patient with DLBCL who was originally diagnosed and treated (R-CHOP) 15 years ago, now with a 2nd primary/late recurrence of DLBCL?
Interesting question - the optimal approach to late-relapsing DLBCL in the modern era is not well defined. Often we will work to clarify if the late relapse is indeed a late relapse as opposed to a second primary - clonality studies on the new and prior lymphoma can be informative in some cases. If ...
Would you consider long term avatrombopag use in patients with cirrhosis requiring higher platelet counts for medical therapy?
In general, no, I would not use long-term avatrombopag in patients with cirrhosis requiring higher platelet counts for medical therapy due to the perceived thrombotic risk and hemostatic abnormalities of patients with liver disease.One thing to note in assessing the risk of long-term TPO mimetic the...
What is your recommended long term management of extensive dural venous sinus thrombosis in an otherwise healthy young patient?
From a Vascular Neurology perspective, there are two considerations when faced with patients with venous sinus thrombosis. First is the status of the intracranial venous circulation and whether or not there has been adequate reconstitution of venous outflow, either through recanalization or collater...
How would you structure your monitoring for a low-risk leukemic TP53-negative mantle cell lymphoma with 5% MCL cells detected in both peripheral blood and bone marrow, mild splenomegaly, and no lymphadenopathy or B symptoms?
This appears to be the prototypical indolent patient for whom observation would be ideal. For these patients, there isn’t a truly validated period of monitoring. I have typically extrapolated from follow-up from other chronic diseases, with a plan to extend follow-up intervals over several years. In...
How would you structure your monitoring for a low-risk leukemic TP53-negative mantle cell lymphoma with 5% MCL cells detected in both peripheral blood and bone marrow, mild splenomegaly, and no lymphadenopathy or B symptoms?
This appears to be the prototypical indolent patient for whom observation would be ideal. For these patients, there isn’t a truly validated period of monitoring. I have typically extrapolated from follow-up from other chronic diseases, with a plan to extend follow-up intervals over several years. In...
What is your preferred adjuvant chemotherapy regimen after a completely resected stage IIIB Granulosa Cell tumor of the ovary?
Recommendation: Patients undergoing surgery with complete resection of tumor for an ovarian granulosa cell tumor (GCT) may be offered systemic chemotherapy or observation. If chemotherapy is offered, I prefer a combination of carboplatin and paclitaxel. Background: GCT of the ovary is the most commo...
How do you manage stage III resectable NSCLC patients treated with neoadjuvant chemoimmunotherapy per CheckMate 816 with residual disease who subsequently refuse surgery?
(1) Carefully analyze what happened with the patient, their medical oncologist, and thoracic surgeon, (2) restage the patient with an FDG-PET/CT and brain MRI to rule out distant metastatic progression, (3) confirm with their medical oncologist that CRT-> Durva is still an option, (4) confirm that a...