Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the appropriate dose of radiation for a primary osseous non-Hodgkin's lymphoma?
Acceptable doses range from 30 Gy to 45 Gy. Would consider 30 Gy if there is a metabolic complete response after 2 cycles of R-CHOP and the patient got at least 4 cycles total. 45 Gy is the dose used in the prospective TROG trial of bony DLBCL, so it has some data behind it. In the femur, the bigges...
When should paclitaxel (or other chemo) be discontinued in de novo metastatic triple negative breast cancer with high PDL1 in favor of continuing pembrolizumab alone with good treatment response?
The KEYNOTE-355 trial was designed so that investigators continued chemotherapy until "confirmed disease progression or unacceptable toxic effects had occurred or withdrawal of consent or physician’s decision" (Cortes et al., PMID 35857659). I think this is a good strategy. It's not a satisfying ans...
What is the role of EGFR inhibitors in patients with metastatic transverse colon cancer?
This is a very tricky question since all the studies including meta-analysis have not clearly addressed this question. If we believe the overall survival difference we observed is truly due to the primary tumor location (sidedness) that is possibly due to the right sided colon being from the midgut ...
Would you offer adjuvant immunotherapy after salvage neck dissection for persistent nodal disease after definitive chemoRT for a patient with p16+ oropharyngeal SCC?
I am assuming that this HPV+ oropharyngeal cancer patient was treated with definitive CRT and then on a 3-month follow-up, PET had persistent nodal disease, which was definitively treated with a neck dissection. If the pathology revealed positive disease, then I would not offer the patient further t...
How do you approach treatment for a patient with T2N0, ER+/PR+, HER2 negative breast cancer with planned TC treatment following a hypersensitivity reaction?
We don't have a trial with albumin bound paclitaxel plus cyclophosphamide vs. TC to guide you here. There is also some conflicting guidance on managing Docetaxel hypersensitivity. On one hand, some references say to rechallenge with Docetaxel is contraindicated (Lenz, PMID 17522249), but if you look...
Will you offer cetuximab or panitumumab with FOLFOX in patients with metastatic left sided RAS/BRAF WT MSS colon cancer instead of bevacizumab?
This is an important question and now we have two studies presented at ASCO attempting to address this. The GONO trial from Italy investigated FOLFIRI or FOLFOXIRI both with panitumumab showing no additional benefit of irinotecan. This was not confined to left-sided tumors but the RR was similar at ...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically use NOACs or Lovenox in patients with stroke due to hypercoagulability from malignancy?
We can extrapolate from studies of venous thromboembolism associated with cancer. Apixaban (at VTE treatment dose) has been compared to dalteparin in an open-label RCT in the CARAVAGGIO trial and edoxaban was compared to dalteparin in an open-label RCT in the Hokusai VTE Cancer trial. Both painters ...
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
What is the best course of action for a patient with isolated carcinomatous meningitis who is responding well to intrathecal methotrexate but now has MRI findings suspicious for methotrexate leukoencephalopathy?
Neurological toxicities of intrathecal methotrexate tend to be categorized by the timeline of onset after treatment. Acute MTX toxicity includes arachnoiditis, encephalitis, transverse myelopathy, and seizures. This tends to be readily reversible including neuroimaging findings. Subacute MTX toxicit...