Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider proceeding with a sentinel lymph node biopsy after wide excision revealed 1.2 mm residual non-ulcerated T2a melanoma on the upper back?
Any melanoma with Breslow’s depth of more than 0.8 mm (more than T1a) needs a sentinel lymph node biopsy for complete staging, due to higher chance of lymph node metastasis. Ideally, it should be done at the time of wide local excision, as doing the sentinel lymph node biopsy afterwards may be more ...
How should medical oncologists and dermatologists communicate about patients with at least Stage IIB/III cutaneous melanoma regarding neoadjuvant immunotherapy?
Only melanoma patients with stage III or resectable stage IV disease should be treated with standard-of-care neoadjuvant immunotherapy. These patients should see a medical oncologist first (and no longer last, as is the current process). I would recommend that the schedulers at your institution be e...
What whole brain radiation dose would you recommend for primary CNS lymphoma with partial response to HD-MTX-R and R-ICE and planned for concurrent ibrutinib?
There are many uncertainties in how to optimal treat patients with PCNSL. It is clear that high-dose MTX-based regimens should be pursued when feasible. The role, if any, of RT is controversial. If pursued, a WBRT-based approach is generally considered most appropriate.With that said, if a patient o...
How will the ADAURA study impact your use of adjuvant chemotherapy?
ADAURA has not and will not impact my use of adjuvant chemotherapy. Many prospective studies have demonstrated a clear significant improvement in overall survival with the use of adjuvant chemotherapy after complete surgical resection. This is standard of care for the appropriate patients. Osimertin...
Do you see a role for ultra-low-dose immunotherapy in your patients with relapsed or refractory solid tumors, and if so, in which clinical scenarios?
To date, there is not enough definitive data to support the use of low-dose immunotherapy. Moreover, ultra-low-dose nivolumab (20 mg Q2W or Q3W) has phase III evidence demonstrating an OS advantage over salvage chemotherapy in pretreated solid tumors, with a favorable toxicity and QoL profile. Its s...
How, if at all, are you modifying your practice and clinical workflow for patients receiving checkpoint inhibitors with data showing improved outcomes for patients receiving infusions earlier in the day?
The paper supporting the 'early morning' approach has been retracted, and arguments against this are being actively pursued for full publication. Recently, data were presented at AACR as well. The half-life of these molecules is quite long (in the range of weeks), which raises a question against the...
Is there greater efficacy of TPO-RA in patients who have undergone a splenectomy?
In the pivotal clinical trials of romiplostim and eltrombopag, there was no strong relationship between splenectomy status and treatment response. In my experience, however, some splenectomized patients exhibit dramatic, rapid increases in the platelet count when treated with a TPO-RA drug, presumab...
When would you offer neoadjuvant immunotherapy prior to Mohs surgery in a locally advanced squamous cell carcinoma for which clearance may require enucleation?
I would flip this question around and answer that radiotherapy is often a terrific option around the eyes, and it should always be considered in this area, especially when a radical surgical procedure is being entertained. Between en face therapy with a shield (superficial, electrons) and IMRT/VMAT,...
Do you always use platinum/5-FU as the chemo backbone with pembrolizumab for recurrent/metastatic H&N cancer?
I prefer to use carbo/taxol with pembrolizumab as well but there is no data to support this and I am having a hard time getting insurance providers to approve. It would be amazing if we can use Mednet platform to create guidelines that might help this cause. Also, I tend to do chemo+pembro for all p...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....