Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you define PIK3CA/AKT/PTEN alteration for capivasertib use?
For CAPItello-291, tumors had to have activating mutations in PIK3CA or AKT or inactivating alterations in PTEN genes – i.e., genes that were altered/not normal. Gene amplification refers to an increase in the number of copies of the same, normal gene, not an increased rate of transcription. So, PIK...
Do you start systemic therapy for patients with previously localized HR+ breast cancer developing solitary bone metastasis which is now triple negative if there are no other sites of disease after metastasis-directed radiation?
I would start chemotherapy because of the triple-negative status of the metastasis. This is a patient who initially presented with hormone receptor-positive breast cancer and subsequently developed an isolated bone metastasis that was triple negative. The question of systemic therapy post-localized ...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What platelet threshold, if any, is your goal for cytoreduction in essential thrombocythemia?
An unusual feature of the myeloproliferative neoplasms (MPN) is that their driver mutations are gain-of-function, meaning that the basic MPN phenotype is the increased proliferation of normal circulating blood cells. This basic phenotype is modified by host genetic variation to create three genetica...
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669
What is the optimal choice of therapy for a patient with Hodgkin variant of Richter's transformation from underlying CLL/SLL?
I treat it similar to denovo Hodgkins Lymphoma with Brentuximab AVD for high risk versus ABVD for standard risk. If EBER-positive lymphoma, then there is a role for rituximab use in addition to chemo. Gupta et al., PMID 35291669
Should immunotherapy be added to standard of care neoadjuvant chemotherapy in borderline resectable MSI-H adenocarcinoma of pancreas?
This is definitely an area worth of trials. We know of the degree of efficacy and tolerability of chemotherapies in this setting. We also are aware of the potential for deep and prolonged response to PD-1 inhibition in patients with MSI-H + high TMB + MMR-d by IHC. I try to utilize immunotherapy in ...
How do you manage the wide array of emotions like anger and disappointment patients may have when they first learn of an incurable relapse of an early stage cancer?
This is a really tough question and there is no easy or straight-forward answer. When I consider situations like this, however, I try to follow these guidelines: I use initial diagnostic uncertainty to my advantage. A diagnosis of relapse is almost never made instantaneously (a suspicious lesion on...
Does a patient with known systemic mastocytosis need a bone biopsy of lytic vertebral lesions to rule out other etiologies?
Yes, as long as other etiologies have been ruled out, such as cancer, osteomyelitis, or other infections. Even though osteoporosis is more common in systemic mastocytosis patients, bone lytic lesions are not.
In which oropharynx patients would you recommend TORS vs upfront RT or chemo-RT?
With MC1675 and ORATOR2 coming out at ASTRO21, and ECOG3311 published shortly afterwards, this topic is now particularly germane. Due to the recent reports on these trials, I'll be writing in the context of possible post-op de-escalation.I think the first and most important question to ask is, "What...