Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...
How would you evaluate a pediatric patient referred to rule out cancer due to an isolated significantly elevated vitamin B12 level?
Would you recommend any adjuvant therapy for a premenopausal woman with ER+, microinvasive breast cancer who cannot tolerate tamoxifen?
I would explain that the benefits of tamoxifen are low, but it may help prevent a new cancer. If she has arthralgias before stopping treatment she may want to try acupuncture to see if it helps her with her symptoms. If she still does not tolerate it she should focus on lifestyle factors such as exe...
Do you evaluate patients for low health literacy prior to discussing treatment options?
To answer this question - I do not routinely evaluate for low health literacy in my patients. This may not be the correct approach, but here is my rationale. I assume low health literacy and work up from there during each consultation. Even patients who are highly educated and/or have a background i...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
Would you recommend radiotherapy to upper-tract urothelial carcinoma in an inoperable patient?
Unfortunately, there are no good data to guide a decision in this circumstance. Assuming that this is a patient with a small tumor localized to the upper tract with no evidence of nodal or distant disease, radiotherapy might be a reasonable option to either palliate symptoms due to obstruction or bl...
Would you consider starting immunotherapy in a patient with stage IV NSCLC, a high PDL1 level, and active, untreated hepatitis C?
The short answer is yes, while also sending the patient to hepatology for HCV treatment. If the patient has minimal disease burden and systemic therapy can be delayed, one small study in patients with NSCLC showed that starting ICI about 14 days after HCV treatment appeared safe. Although patients w...
How do you approach cisplatin ineligible patients with bulky EBER positive nasopharyngeal SCC for induction chemotherapy?
For patients who are cisplatin-ineligible, I substitute with carboplatin. There have been studies such as the one below which show that the regimen of carboplatin and gemcitabine is effective and well-tolerated. Lim et al., PMID 23369852 Conclusion: The use of induction carboplatin and gemcitabine f...
Has use of PSMA PETCT revealed increased local failures than previously known after definitive prostate EBRT with biochemical failure?
Prior to the advent of PET imaging, the published rates of local recurrence (LR) after definitive RT vary widely in phase III trials from ≈ 1% (e.g., PCS IV) to ≈ 30% (e.g., PROG 9509). The heterogeneity is likely explained by several factors including (1) differences in baseline risk of local recur...
How would you manage a cT4N0 HER2- distal esophageal adenocarcinoma, CPS score 30, with good response to neoadjuvant chemo-RT on PET and residual disease on EGD in a patient who declines surgery?
There's really no good answer here. What one does is predicated largely on how much faith one has in the efficacy of nivolumab.The benefit of adjuvant nivolumab in patients with locally advanced esophageal cancer who underwent trimodality therapy and had residual disease is of course based on the Ch...