Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Have you changed your practice in treating CRAO with IV thrombolysis?
The recent THEIA trial had a limited sample size to draw conclusions, even though there was a non-significant trend of improved visual acuity initially in the thrombolysis group. Even the TenCRAOS trial had a small sample size with recruitment challenges, where subtle small differences cannot be acc...
How do you present the trade off between a small chance of a sustained response for a new drug at the expense of potential worsening quality of life?
Since we now have an increasing number of treatments at our disposal, this becomes an ever more frequent conversation in oncology. This question gets at several Shared Decision Making (SDM) model steps. Usually in this scenario, there are not routine standard of care options and highlighting the pat...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
In a patient who has been receiving 1L Ibrutinib for TP53+ CLL for years with complete hematologic response but detectable MRD, is there any role to switch to the novel BTKi agents given better PFS?
There are a couple of features to this question that need comment. First, the goal of therapy with a single-agent BTKi, regardless of ibrutinib, acalabrutinib, zanubrutinib, or pirtobrutinib, is NOT to achieve undetectable MRD. Very few patients will achieve this milestone due to the drug's MOA. BTK...
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...
How would you treat a patient with aggressive metastatic cutaneous squamous cell carcinoma, which is not amenable to surgery or radiation?
Often the first question is how the patient got to this point. Is this someone who has neglected a squamous cell carcinoma, or perhaps many, or is this someone who has had multiple surgeries and radiation treatments and is finally beyond that, or is this perhaps an immunocompromised patient, usually...
Would you consider using transdermal estrogen in a patient with “high risk” APLS patient on warfarin?
Given her clinical diagnosis of high-risk APS, I would first trial nonhormonal therapies or progesterone-only therapies for management of her post-menopausal symptoms. Current ACR guidance recommends against hormone replacement therapy in patients with APS on anticoagulation (Sammaritano et al., PMI...
How do you decide which immunotherapy agent to utilize for 1st line in PD-L1 high (>50%) NSCLC?
Now with the approval of atezolizumab based on the positive Impower110 study (led by @Dr. First Last and @Dr. First Last), we have 2 frontline checkpoint inhibitors to choose from. Indeed the data appears very convincing for both, therefore on scientific grounds, I would not be able to choose one ve...
When do you suggest ovarian suppression for fertility preservation in premenopausal women receiving neo/adjuvant chemotherapy?
The benefit of ovarian suppression in young breast cancer patients should be looked into from two different aspects. First, the suppression of the ovary resulting in the hormone receptor-dependent cancer stem cell (minimal residual disease) suppression, and second, the preservation of the fertility ...