Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you screen adults in your practice with sickle cell disease for silent cerebral infarcts?
The details of the ASH guidelines regarding adults are complex. It was not my practice to screen all patients. More than 50% of adults have silent infarction. Screening requires MRI and this, according to the guidelines, needs careful attention to many details before it is reliable. There are no pro...
Would you restart prophylactic anticoagulation in a patient with a history of unprovoked PE who received short term anticoagulation with a prior physician?
The decision on duration of anticoagulation should balance the risk of hemorrhage vs risk of recurrent VTE. The annual risk of recurrence with unprovoked venous thromboembolism (VTE) is definitely higher than provoked VTE and seems to be higher in males than females.According to one study (Rodger et...
Do you recommend a kidney biopsy for patients who develop acute kidney injury after starting sacituzumab?
For all novel agents, I think that it is prudent - if there are no contraindications to the renal biopsy - to proceed with a biopsy. A renal biopsy is helpful in clarifying the etiology of the AKI and may have implications regarding whether the medication can be safely continued - depending on what ...
For patients doing well on targeted therapies (alectinib, osimertinib) for metastatic NSCLC, what data / guidelines do you use to decide about holding treatment before/after surgical procedures?
When would you use PSMA PET over conventional imaging for prostate cancer?
So far, most (but not all) prospective data for molecular imaging has been obtained in the setting of biochemical recurrence and that is where I have used it most outside of trials.In the primary disease setting, some trials examined the utility to detect nodal and distant disease (like OSPREY publi...
What is your approach to neoadjuvant chemotherapy for a T3N0 mid-rectal cancer?
All patients with rectal cancer should have a detailed and careful evaluation with high quality MRI (hopefully with a rectal cancer staging protocol) to have accurate staging workup. However, no matter how great the quality of the study we have, there are always staging errors. The current guidelin...
In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?
I would offer cytotoxic platinum doublet chemotherapy and omit immunotherapy based on emerging data that TKI adverse events are often worse after prior immunotherapy exposure (Calles et al., PMID 32421452). The choice and dose of cytotoxic doublet will depend on the individual circumstances of each ...
With the accelerated approval of Brigatinib, and now three approved ALK inhibitors in the 2nd-line setting, how do you decide between these agents?
A biopsy should be considered for ALK-rearranged lung cancer patients who previously received crizotinib and developed progression whenever safe and feasible. While most patients with acquired resistance to crizotinib will respond to a next-generation agent, and mutational profiling is not strictly ...
What is your approach to treat metastatic poorly differentiated thyroid cancer with papillary features?
The easy answer is that there is a role for I-131 if the remnant disease (tumor bed or mets) is iodine avid. Harder and perhaps more realistic is that the test dose of 2-3 mCi is too low and you have to overwhelm the iodine receptor with at least 30 mCi to activate a radiologic response. If you are ...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...