Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What radiation treatment volume and dose would you deliver to an isolated DLBCL relapse in the left eye s/p vitrectomy and intraocular methotrexate?
This is a case of secondary ocular lymphoma but the management of primary ocular lymphoma may be helpful to consider. For patients with primary ocular lymphoma, a significant number of patients present with bilateral disease at initial diagnosis or will relapse in the contralateral eye after unilate...
Aside from adrenal insufficiency and thyroid toxicities, how do you approach other hormonal imbalances during treatment with immune checkpoint inhibitors?
A systematic review (Barroso-Sousa et al., PMID 28973656) indicated that hypophysitis can occur in 3.2% of patients treated with ipilimumab (Yervoy) and this increased to 6.4% when combined with nivolumab (Opdivo). Obviously, adrenal and thyroid functions need to be assessed first but other function...
What is the appropriate approach to manage a patient with triple-negative, locally advanced breast cancer (LN+) who progresses on neoadjuvant chemo-immunotherapy (KEYNOTE-522 regimen)?
Given the aggressiveness of the KEYNOTE-522 regimen, second-line chemo seems unlikely to be effective. Assuming the patient is currently not resectable, recommend breast RT concurrently with a well-tolerated radiosensitizer, e.g., capecitabine, dose, and fractionation depending on the presence or ab...
Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?
Background: We know that inflammatory bowel disease (IBD) is a risk for incident and recurrent venous thromboembolism (VTE). What is not clearly established is whether the IBD needs to be 'active' in order for it to be a risk factor, e.g. would patients who have had proctocolectomy (and perhaps no e...
When would you continue bevacizumab versus using PARPi alone for maintenance therapy in BRCA+ or HRD+ ovarian cancer after response to primary platinum + bevacizumab?
In patients who start treatment with combination platinum based chemotherapy + bevacizumab, and are found to be BRCA+ or HRD+, I will commonly continue bevacizumab and layer on the PARPi in the maintenance setting. This is based on both the PAOLA-1 data, as well as the population adjusted indirect c...
Would you change an elderly, frail patient with atrial fibrillation who is already on a NOAC to VKA treatment?
I wouldn't on the basis of this study. Aside from the other limitations of the FRAIL-AF trial, this study only addressed the utility of switching a stable patient from VKA to NOAC and not vice versa. A patient who is doing well on an appropriately dosed NOAC may experience difficulty achieving adequ...
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
With the intent for cure, what neoadjuvant therapy would you give a patient with only chest wall recurrence 10 years after an advanced breast cancer was managed with mastectomy, ddAC and T, and 5 years of adjuvant endocrine therapy?
A chest wall recurrence is associated with high risk of metastatic disease either at time of diagnosis of the chest wall recurrence or over the next 5 years. Women who develop chest wall recurrences should be restaged. The approach to an isolated chest wall recurrence in this case is surgery with cl...
How do you counsel patients with locally advanced malignancies who have ECOG 3-4?
I agree with @Dr. First Last and @Dr. First Last's comments about the implications of PS and specific situations where medical therapies have the potential to improve PS (heme malignancies small cell) and/or extend quality of life. I have two goals in this conversation. To make sure I understand the...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...