Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer adjuvant chemotherapy to a patient with T3N0M0 NSCLC if the reason for the T3 stage was due to multiple tumor nodules in the same lobe?
I discuss and offer adjuvant chemotherapy to these patients recognizing the fact adjuvant chemotherapy recommendations are not solid in this specific subset of patients. Based on the 8th TNM staging system they would have an overall stage of IIB which means they still have a significant risk of dise...
How would you approach treating patients with RA refractory to cDMARDs and a prior history of MALT lymphoma?
If the concern is the risk of recurrence of lymphoma in a patient with RA requiring DMARD therapy, particularly biologic DMARD therapy, rituximab has not been associated with recurrence or even new onset lymphoma. Rituximab is a highly efficacious biologic DMARD for seropositive RA. This is consiste...
For patients with early stage T1/T2 N0 low rectal cancers who are not candidates for transanal surgery and decline APR due to ostomy, would you offer chemoRT followed by surveillance or chemoRT, then a course of chemotherapy followed by surveillance?
This rectal cancer patient obviously has very limited options since transanal surgery and APR are off-the-table. In our clinic, we have similar situations from time to time but most of the time is that the patients who have T3 or N+ rectal cancer decline an APR. Since the patient has active tumor in...
In a patient with sickle cell disease on hydroxyurea who is planning to have a family, for how long should they be off the drug before trying to conceive?
There is some consensus that pregnant women should not take hydroxyurea and should stop taking this when found to be pregnant. (Smith-Whitley, PMID 25472967) As far as I know, there is no data on how long hydroxyurea should be discontinued in either men or women before attempting pregnancy. In fact,...
How would you approach potential SBRT to liver metastases in a patient on a VEGF inhibitor?
For patients who are on VEGF inhibitors, I would be very careful with dosing of radiation to nearby bowel and I discuss holding VEGF inhibitors for a time before, during and after radiation. There have been multiple reports of in field toxicity, particularly with respect to bowel (liver SBRT frequen...
In sickle cell patients with continued pain crises despite hydroxyurea, how do we sequence the use of newer agents?
As the data supporting the approval of crizanlizumab in NEJM by Ataga et al demonstrated improvement in pain, that is our usual next agent based on the question of pain crises. The approval data around voxelotor related to an increase in hemoglobin of about 1gm/dl, so it may have a different role an...
Would you offer intensive CNS prophylaxis to Ph negative B-ALL patients who have possible mandibular nerve involvement on MRI face?
I would be inclined to treat this patient according to the CNS3 schedule of CNS-directed prophylaxis.Mental nerve neuropathy (or "numb chin syndrome," a rather pedestrian-sounding term for which I cannot take credit) can be a sign of leptomeningeal disease, presumably due to more focal involvement a...
Would you offer intensive CNS prophylaxis to Ph negative B-ALL patients who have possible mandibular nerve involvement on MRI face?
I would be inclined to treat this patient according to the CNS3 schedule of CNS-directed prophylaxis.Mental nerve neuropathy (or "numb chin syndrome," a rather pedestrian-sounding term for which I cannot take credit) can be a sign of leptomeningeal disease, presumably due to more focal involvement a...
What is your preferred treatment for locally advanced poorly differentiated carcinoma of the nasopharynx with bulky neck nodes that is EBER negative and p16 negative?
I prefer concurrent chemoradiation first if this can be started in a timely fashion and deemed reasonable by my radiation oncology colleagues. Discussion in multidisciplinary tumor board would be of immense value here. I would strongly consider adjuvant chemo based on Intergroup 0099 study in which ...
With the recent ODAC review of the commerically available CAR-T therapies in relapsed/refractory myeloma post 1-3 lines of therapy, what is your preferred regimen/therapy for first relapse, and which are the situations where you would absolutely consider CAR-T therapy at first relpase?
So, in a twist that almost never happens in myeloma, I largely still agree with my answer from a year ago: https://www.themednet.org/question/16578 In brief, at that time, I'd suggested that CAR-T primarily be used from the third line onwards - i.e., after at least two prior lines have failed. I st...