Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Would you give immunotherapy after neoadjuvant gem-cis for bladder cancer if cystectomy is being postponed for months due to non-autoimmune/unrelated comorbidities?
Delay in cystectomy regardless of the use of neoadjuvant chemotherapy is associated with compromised survival outcomes (Chu et al., PMID 30840335) and if a patient receives neoadjuvant chemotherapy and is unable to undergo cystectomy for months due to comorbidities, there is no clear data to support...
In patients with perihilar cholangiocarcinoma eligible for liver transplant, what is the protocol for neoadjuvant chemo-RT, particularly when brachytherapy is not available?
There is a lot of variability in neoadjuvant regimens prior to transplant for hilar cholangiocarcinoma as outlined in the survey paper above. Institutional approaches for total dose, fractionation, and target volumes vary considerably. A couple of points to consider and some personal opinions - Phil...
What factors aside from progression do you consider most important in determining whether a patient with metastatic papillary thyroid carcinoma is radioactive iodine refractory?
RAI refractory or resistant is defined as: Progression despite adequate RAI RX within the prior year after therapy Tumor that does not take up RAI either on a diagnostic or post-therapy whole body scan
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...
Is there a role for reirradiation for SCC oral tongue with high-risk features (i.e., PNI, close margins) following surgery?
Consider in patients with ENE, positive margins, deeply infiltrative tumors (>1 cm), or T4. Avoid if <6 mo from prior RT, ongoing wound healing issues in target, or pre-existing severe toxicity (e.g., ORN, severe fibrosis), though this is conditional.
Which PARP inhibitor do you recommend for maintenance therapy in BRCA mutated ovarian cancer after primary chemotherapy and why?
Given the abundance of both efficacy and safety data available for Olaparib in this setting, I use Olaparib for maintenance therapy in BRCA+ ovarian cancer patients after primary chemotherapy. The 5-year PFS data from SOLO-1, confirming sustained benefit beyond the end of treatment, further speaks t...
Would you offer surgery for an MSI-H pancreatic adenocarcinoma who had deep response to pembrolizumab?
This is a hard question. The 19-9 gives me pause (even with normalization) and I think most likely I would push on with checkpoint inhibitor therapy for a total of two years given that it is very unlikely surgery will clear disease and ICI may get you to a durable complete response on its own. I don...
In an elderly transplant ineligible IDH1-mutated patient with AML, who is in remission after 6 cycles of azacitidine and ivosidenib, would you discontinue azacitidine after cycle 6 and continue maintenance ivosidenib until progression/toxicity or continue both azacitidine and ivosidenib?
Our practice is to typically continue azacitidine + ivosidenib per the AGILE study (Montesinos et al., PMID 35443108) as long as the patient is not having excessive myelosuppression/toxicity and doesn't feel strongly about coming off azacitidine. That being said, there are data to support ivosidenib...