Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For a completely resected high risk adrenal cortical carcinoma with a high mitotic rate, what is your approach to adjuvant therapy?
I do not ROUTINELY use adjuvant therapy for completely resected adrenal carcinoma. I think that the quality of surgery is more important, and generally am more comfortable if this has been undertaken by an experienced urologist or endocrine cancer surgeon who has achieved R0 status (full pathologica...
How are you approaching patients who receive neoadjuvant chemo immunotherapy for resectable NSCLC who after completion of neoadjuvant treatment are no longer surgical candidates due to factors such as toxicity, decline in PS, or patient preference?
This scenario seems to happen in 17-20% of patients. It’s very important to appropriately stage patients at diagnosis with PET CT, EBUS, etc to ensure accurate staging without which a good discussion regarding resectability is not possible. If a patient does, in spite of our due diligence, end up no...
What impacts your decisions regarding the use of immunotherapy in metastatic G/E/GEJ cancers overall in light of variations in FDA approval, guidelines, and trial data?
The decision really lies in balancing the likelihood of benefit against potential toxicity. Checkpoint inhibition is generally very well tolerated, but there are patients that I am hesitant to consider it, including patients with rheumatoid arthritis, inflammatory bowel disease, or other autoimmune ...
How is transferrin saturation a reliable indicator for any parameter if serum iron is not reliable?
The question is a very good question. The Fe/TIBC must be drawn on an overnight fast including any vitamin pills containing iron. Otherwise, the serum iron is speciously elevated which in turn speciously elevates the TSAT. If those conditions are met, the TSAT is as good as the transferrin receptor ...
What is your approach to solitary node positive bladder cancer (e.g. N1) in a patient who is otherwise a candidate for either bladder preservation or radical cystectomy?
This is a very intriguing question, with limited prospective data to guide us. I will frame my response on a patient with clinical node positive (based on imaging) bladder cancer and a candidate for bladder preservation or cystectomy. This patient is deemed metastatic yet there may be a subset of t...
What subset of sickle cell disease patients are you offering sickle cell disease gene therapy?
All patients with Hgb SS and patients with Hgb SC who have had any significant complications, excluding chronic pain.
When do you refer AYA patients with newly diagnosed severe aplastic anemia for transplant?
In a young person, my first thought is to obtain telomere lengths to be sure he/she does not have a telomeropathy. This has significant implications both with and without transplantation. Certainly, if telomeres are short, allogeneic transplantation is preferred since there is less likelihood of res...
When do you refer AYA patients with newly diagnosed severe aplastic anemia for transplant?
In a young person, my first thought is to obtain telomere lengths to be sure he/she does not have a telomeropathy. This has significant implications both with and without transplantation. Certainly, if telomeres are short, allogeneic transplantation is preferred since there is less likelihood of res...
How do you approach adjuvant chemotherapy in resected T4N0 colon cancer?
How would you approach adjuvant treatment for a premenopausal woman with a large, lymph node positive HR+, Her2 negative lobular breast cancer?
In pure or classical estrogen receptor positive lobular breast cancers neoadjuvant chemotherapy works very poorly (3% vs 15% pCR; Cristofanilli et al. J Clin Oncol 2005;23:41-8) and you are not likely to convert mastectomy to lumpectomy. I would strongly consider neoadjuvant endocrine therapy, espec...