Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are outpatient strategies to mitigate taxane-induced peripheral neuropathy?
At the present time, there are no established means for preventing taxane-induced neuropathy other than limiting the dose that is given. In patients who are receiving taxane therapy and have developed significant neuropathy, ASCO guidelines suggest that discussion should be had with patients with re...
Would you continue to monitor urinary protein levels and dose adjust axitinib in a patient with metastatic malignancy who is now dialysis dependent but has residual renal function?
The question lacks specificity, so I will assume that this refers to a patient with irreversible ESRD not due to the TKI itself. Generally, if the proteinuria was exclusively due to the TKI, the HTN and proteinuria will abate when the drug is discontinued. Also, as renal function declines, the prote...
What is your approach to persistently low INR despite escalating doses of warfarin in a patient with bioprosthetic mitral valve replacement who is unable to be on DOACs?
The assumption here is that the mitral valve is mechanical, or there are presumably other reasons that a DOAC cannot be used. If this is, in fact, a mechanical mitral valve, it would make sense to start with low molecular weight heparin injections as soon as feasible while awaiting a therapeutic INR...
How would you sequence adjuvant chemo-immunotherapy (paclitaxel/carbo/pembro or paclitaxel/carbo/dostarlimab) with EBRT and vaginal cuff brachytherapy in advanced uterine cancer that meets clinical criteria for both EBRT and chemo-IO?
A common misapplication of RUBY/GY018 is giving IO in patients with non-measurable advanced uterine cancer. Radiation as part of the trial was not included in these studies. The role for chemo-IO vs chemo alone (with or without radiation) for high risk non-measurable uterine cancer was tested in GOG...
Given the results of KEYNOTE-A18, do you plan to recommend adding pembrolizumab to primary chemoradiotherapy for advanced stage cervical cancer?
Until the paper gets published, we won't really know a lot of details that may influence the potential utility of this regimen. It has an abstract/presentation and has recently received FDA approval.It is a relatively 'newer' idea in improving outcomes that we as an institution are open to start off...
Is REZUM (water vapor thermotherapy for BPH) safe after EBRT?
Although I am not aware of any studies evaluating the toxicity rates in patients undergoing REZUM after RT, I am aware of a few studies reporting the toxicity of TURP after RT. For example, Liu and colleagues conducted a retrospective review of the outcomes of 1,192 patients, 246 of whom underwent a...
Are there any adverse risk factors in stage I colon cancer that would warrant ctDNA testing?
I would not check ctDNA in this setting. If there is an adverse feature of the tumor and the patient is a candidate for further treatment, I would do close surveillance imaging and CEA at the most. A recent publication of a larger cohort study of stage II to IV resected colorectal cancer suggests th...
How would you manage a large area of multiple, recurrent cutaneous squamous cell carcinomas of the scalp with ulcerations and non-healing areas despite cryotherapy, multiple Mohs procedures, and 5-FU?
Consider sending the patient to medical oncology for evaluation for cemiplimab. Large areas of the scalp can also be treated by making a 1 cm "cap" of bolus and utilizing VMAT to cover scalp soft tissues, with elective coverage of nodes and perineural pathways if indicated.
What is your preferred choice of therapy for first-line treatment of a patient with good, intermediate, or poor risk stage III nonseminomatous germ cell tumor if the patient is truly cisplatin-ineligible?
The first question is what makes the patient "cisplatin-ineligible". Cisplatin has been given in patients on hemodialysis, guided by cisplatin levels and timing of dialysis. In someone with first-line intermediate and poor-risk disease, cisplatin is indispensable in my view.
What is your preferred mode of vascular access for testicular cancer regimens?
Actually, we try to avoid all vascular access devices, especially PORT, which causes a 10-20% risk for clot as well as infection. These are young healthy patients usually with excellent veins. Over 90% of our large patient populations with testis cancer simply get their 5 days of chemo with a restar...