Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage liver-metastatic pancreatic neuroendocrine tumor after progression on a somatostatin analogue, chemotherapy, immune checkpoint blockade, and embolization?
The optimal sequencing of systemic therapy beyond somatostatin analogs (SSAs) in patients with pancreatic NETs (pNETs) remains to be determined. Assuming that regional therapy is not feasible, there are several options such as capecitabine/temozolomide (CAPTEM), everolimus, sunitinib, and PRRT. The ...
How would you counsel a female to male transgender patient regarding VTE risk with testosterone therapy, who has additional mild-moderate risk factors for thrombosis?
If physiologic concentrations of testosterone are not exceeded and the hematocrit is monitored to avoid a pathologic level of erythrocytosis, the risk for thrombosis from testosterone GAHT does not appear to in excess of the general population. I would refer you to the following two articles that pr...
How do you treat clear cell renal cell carcinoma with metastatic recurrence while on adjuvant pembrolizumab?
My colleagues and I recently tried to address this question in a review paper in the Kidney Cancer Journal which is worth a read. In the absence of prospective data in this space, we provide recommendations for clinicians based on existing evidence and constructed a potential algorithm to consider....
What is your approach to symptomatic superficial thrombosis of the pelvic veins occurring in the immediate postpartum period?
I would strongly consider anticoagulation in this scenario given the high risk of thrombosis in the postpartum period.Generally, there is a low threshold to place patients on prophylactic dose anticoagulation for six weeks postpartum (personal history of thrombosis, inherited thrombophilia) given th...
When, if ever, would you initiate chemotherapy for recurrent colorectal cancer based on a positive ctDNA assay alone, such as Signatera, in the absence of tumor on imaging or physical exam?
No. There are many ongoing trials to look at this question and stay tuned for a soon in press JCO review that will reference many of the studies but currently, no data to treat based on a positive test. I will be more mindful of surveillance i.e., a 3-month scan, for example.
How would you approach unexpected chemo breaks during planned neoadjuvant chemoradiation for esophageal adenocarcinoma?
Local regional failure compromises quality of life
How do you choose the appropriate first line treatment between everolimus, somatostatin analogues, or cytotoxic chemotherapy in patients with good ECOG PS and widely metastatic atypical carcinoid of the lung?
If the patient is not symptomatic from tumor burden, can start with somatostatin analogues and then add everolimus on progression. Cytotoxic chemotherapy for patients who have progressed on everolimus.
Would you recommend anticoagulation in subsequent pregnancies after symptomatic postpartum R ovarian vein thrombosis?
The 2018 ASH guidelines recommend the following: For women not already receiving long-term anticoagulant therapy who have a history of VTE, the panel makes the following recommendations: Unprovoked VTE (strong recommendation, low certainty): and provoked VTE, hormonal risk factor (strong recommendat...
What would you recommend as first line therapy for metastatic chromophobe RCC?
Albeit limited data, I favor an IO-TKI doublet for chromophobe RCC. The recent B61 trial with Len/Pembro showed a response rate in the 25% range for this historically IO non-responsive subtype. I think all patients should get an IO-based regimen up front as no other regimens have curative potential....
How do you treat metastatic large cell neuroendocrine carcinoma of prostate with undetectable PSA, who had the treatment related transformation while on ADT monotherapy?
Treatment-emergent (or extra-pulmonary) high-grade neuroendocrine carcinoma (sometimes labeled HG-NEC or EP-NEC) is an increasingly seen phenomenon with the more widespread use of ARSI in the first-line setting. This is a distinct entity from prostate adenocarcinoma with neuroendocrine differentiati...