Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
At what PSA level would you consider restaging a patient who was treated with ADT and radiation and had undetectable PSA?
The criteria for defining PSA relapse after radiation therapy remains the Phoenix criteria (see Roach et al., PMID 16798415), which is essentially nadir + a 2 point rise in serum PSA. Thus, a patient who achieves an undetectable PSA on ADT/RT but then experiences a PSA rise would not meet PSA relaps...
Do you routinely use higher-dose VTE prophylaxis in patients admitted with traumatic orthopedic injuries undergoing surgery?
Yes, at my institution, we have two separate order sets. One is for moderate-risk medicine patients, which recommends enoxaparin 30-40 mg daily depending on renal function (heparin for ESRD and low-weight patients). The other is for high-risk patients, which includes all orthopedic and trauma patien...
What is the role of radiation therapy in recurrent Rosai-Dorfman disease after surgical resection, which manifests as many cutaneous lesions on the arms and buttocks?
I agree with Dr. @Dr. First Last. When I was in training, we reviewed the cases at MD Anderson. Radiation was only used for 9 patients (infrequently), and local control was achieved in 4 patients. So very small numbers, with uncertain benefits. Median RT dose 36 Gy. In the setting of multifocal dise...
How do you best incorporate use of filgrastim/pegfilgrastim in capecitabine based regimens?
Neutropenia during capecitabine is almost always a dose-related issue. Neutropenia can be thought of as a pharmacodynamic marker of drug exposure. If a patient is experiencing dose-limiting neutropenia during capecitabine-based therapy, they are likely receiving an excessive dose of one of the chemo...
How do you start and manage therapeutic SC heparin for acute thrombosis in pregnancy as the patient approaches delivery?
This is an excellent question and my approach to such a patient has changed over time. In my experience, therapeutic subcutaneous UFH is incredibly unpredictable--women may come in in labor on therapeutic UFH thinking that they will be able to get an epidural, but despite waiting hours and hours, th...
Do you offer patients with advanced endometrial cancer lower starting doses of lenvatinib when used in combination with pembrolizumab given high adverse event rates with 20 mg daily?
For the first part of the question, "Do you offer patients with advanced endometrial cancer lower starting doses of lenvatinib when used in combination with pembrolizumab given high adverse event rates with 20 mg daily?" The strategy of administering lenvatinib therapy by starting at the established...
Is there a difference in the incidence of serious immune-related adverse events with the lenvatinib + pembrolizumab combination vs pembrolizumab alone in endometrial cancer?
Yes, high risk of both hypertension and diarrhea. The diarrhea can be very difficult to manage. The lenvatinib definitely adds a level of complexity to the management of pembro side effects. This requires dose reductions and interruptions, maybe even hospitalization for dehydration/renal insufficien...
What is your preferred first line systemic treatment for recurrent, metastatic, low grade, ER/PR+ pMMR endometrioid endometrial carcinoma?
Given the data presented at the most recent SGO Annual Meeting on Women's Cancer, published simultaneously in the New England Journal of Medicine, and recently endorsed by the National Comprehensive Cancer Network (NCCN), the standard of care for recurrent endometrial cancer, regardless of MMR statu...
Does the degree of ER/PR positivity influence your treatment option in the patient with newly diagnosed metastatic breast cancer?
There is robust evidence showing that breast tumors with a low percentage of hormone receptor expression derive a smaller benefit from endocrine therapy compared to patients with strong hormone receptor expression. In fact, breast cancers that are only weakly hormone receptor-positive with <10% ER e...
Do you routinely check tumor genomics, including POLE status for new endometrial cancers?
This is an evolving question! My first comment is if it's not going to impact your treatment decisions, probably best not to order. But with increasing data to suggest the POLE mutated tumors may not require as intense therapy, it would certainly be reasonable to order - especially as a "tie-breaker...