Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred way of administering nivolumab/ipilimumab in GI cancers?
Thanks for the question.My preference would be Nivo 3 Q2W & ipi 1 Q6W due to the more favorable toxicity profile seen in the first-line CheckMate-142 trial (Lenz et al., PMID 34637336) compared to CheckMate-142 that was conducted in refractory setting (Overman et al., PMID 29355075). Thanks
How would you approach Grade 2-3 rash due to erlotinib for a patient with metastatic EGFR mutated lung adenocarcinoma that is well controlled for > 5 years and NED by PET?
This is a favorable challenge to approach given the complete response on erlotinib for more than 5 years. In addition to treating the current grade 2-3 rash with a 7-10 day interruption of erlotinib, a short course of oral steroids, and aggressive local skin treatment, I would approach based on seve...
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
How would you optimally manage a patient with a MDS/MPN overlap syndrome who has both transfusion-dependent anemia and marked thrombocytosis?
Patients with MDS/MPN marked by severe anemia and thrombocytosis likely have the MDS with ring sideroblast with thrombocytosis (MDS-RS-T) subtype and have a high frequency of SF3B1 and JAK2 mutations. Clinically, they resemble a fusion of MDS-RS and essential thrombocythemia (ET), both of which tend...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
When do you use clinical decision tools, like HERDOO2 or DASH, to determine duration of anticoagulation in venous thromboembolism?
I do not use the clinical decision tools as I find that they do not properly account for all variables that impact anticoagulation decision-making in a patient-by-patient case.
What are your top takeaways in Breast Cancer from ASCO 2023?
SONIA: A notable trial comparing CDK4/6 inhibitors as 1st line vs. 2nd line treatment. AI+CDKi combination therapy as 1st line does not improve OS, 2nd PFS, or QOL compared to combination therapy as 2nd line. Factors such as the site of metastasis, tumor burden, symptoms, cost, and side effects sho...
What is your bilirubin threshold to treat a metastatic pancreaticobiliary tumor with FOLFOX?
I am not aware of any particular threshold, but as the clearance of 5-FU and oxaliplatin is minimally affected by hepatic dysfunction, both drugs can be used. In my personal experience, I have treated patients with bilirubin more than 10 with FOLFOX (generally without a 5-FU bolus which likely has m...
How do you manage a patient with no history of miscarriage but who is unable to conceive, who has a positive lupus anticoagulant without diagnosis of antiphospholipid syndrome?
I would be very leery of linking infertility to a positive lupus anticoagulant result. Whether or not the patient has antiphospholipid syndrome the evidence linking antiphospholipid antibodies to infertility (as opposed to loss of an established pregnancy) is somewhere between weak and nonexistent. ...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...