Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In what situations do you use G-CSF for patients undergoing allogeneic HSCT to facilitate engraftment?
A word of caution regarding the use of G-CSF in the setting of using ATG for GVHD prophylaxis. We published in 2021 (Orfali et al., PMID 34507002) a multicenter retrospective analysis of the interaction between ATG and post-transplantation G-CSF on allogeneic HCT outcomes for myeloid malignancies an...
Do you give two or three cycles of cisplatin to patients with H&N squamous cell carcinoma receiving chemoradiation with Q3 week cisplatin?
The data from an old RTOG study show that a total of 2 cycles of cisplatin 100 mg/m2 concurrently with accelerated RT is as good as 3 cycles with standard RT. My experience is that most patients do not tolerate cycle 3 of high dose cisplatin and therefore, not given. Personally, I do not routinely u...
Do you refer all patients with new findings of CNS or epidural mets/tumor to ED for evaluation or are there some that can be managed completely outpatient?
Interesting question: Sending patients to the ED for non-emergent conditions is not advised. Our EDs around the country are struggling for a variety of reasons (e.g., they are often holding patients awaiting placement or admission), thus our society will benefit by us avoiding sending patients to t...
How would you sequence lifileucel (TIL therapy) in a patient with metastatic melanoma who is BRAF wild-type (BRAF WT) and progressed on adjuvant Nivolumab?
The FDA-approved label for Amtagvi is for BRAF wild-type metastatic melanoma patients who progressed following anti-PD-1 containing immune checkpoint therapy. Thus, progression following ipi/nivo would certainly meet the indication for TIL therapy. What you will have to assess though is whether the ...
What are the treatment options for patients with duodenal cancer who have progressed on FOLFIRINOX?
The quality of evidence for almost all treatments in small bowel adenocarcinomas is poor to some extent. First, I would look at the NGS data I am sure you have or can obtain easily for a molecular treatment if applicable (TMB > 10 = pembrolizumab, MSI-H = checkpoint inhibitor, NTRK = e.g. entrectini...
What systemic therapy would you offer a patient with metastatic melanoma who is BRAF WT and developed metastases while on adjuvant nivolumab?
Adding an anti-CTLA4 agent after progression on anti-PD1 (even in the adjuvant setting) should be a reasonable choice for patients who are ineligible for clinical trials. In our practice, we recommend using the CheckMate 067 dose (Ipi 3 and Nivo 1) when faced with such a situation. Zimmer et al., PM...
In what situations do you utilize G-CSF in germ cell tumors or Hodgkin lymphoma patients receiving bleomycin?
Having been both a lymphoma doctor and germ cell tumor doctor, I can tell you our experience. The current standard for poor risk germ cell tumors is to routinely include G-CSF with BEP X 4 and VIP X 4 in most high volume centers. A number of experts include growth factors routinely in good risk pati...
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
How do you approach very treatment-refractory ITP?
Severely refractory ITP doesn't account for a large fraction of ITP patients, but it can be quite a challenge for treaters and patients alike. Combination therapies, varied immunosuppressive agents, and careful checks on adherence are all helpful. Some alternative agents with entirely different mech...
How do you approach very treatment-refractory ITP?
Severely refractory ITP doesn't account for a large fraction of ITP patients, but it can be quite a challenge for treaters and patients alike. Combination therapies, varied immunosuppressive agents, and careful checks on adherence are all helpful. Some alternative agents with entirely different mech...