Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage grade 3 enterocolitis from 5FU mitomycin and pelvic radiotherapy?
With infection ruled out and CT showing diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field, presumably, it is due to the 5FU/mitomycin. In the few cases I have had, it generally heals 2-3 weeks after counts nadir. Besides supportive care (Imodium, Lomotil, Gas-X, ti...
How would you approach cytopenias 5 weeks after initial dosing in a young patient with MDS treated with Azacitadine as a bridge to transplant?
Bridging with HMA to transplant in MDS patients is a common practice although it did not show improved outcomes. You will definitely have to r/o other potential causes of pancytopenia (i.e., infections, etc). I would repeat a BM A/Bx to make sure that blasts are not increasing (< 20% and preferably ...
Do you recommend adjuvant chemotherapy in a patient with node positive gastric adenocarcinoma with mixed dMMR/MSI histology?
Well, this is certainly a situation where treatment decisions are completely unburdened by data and one could do virtually anything, from observation to immunotherapy plus chemotherapy.A more straightforward version of this scenario is if the patient has a fully resected node-positive dMMR/MSI gastr...
How would you approach second line treatment for prostate adenocarcinoma with diffuse neuroendocrine features?
Men with NEPC (histologic evidence of small cell carcinoma) face a poor prognosis and are typically refractory to all hormonal interventions, and in fact transformed NEPC much more typically evolves after potent AR inhibition than present de novo at diagnosis. Autopsy series and biopsy series sugges...
What are your takeaways from the GPRC5D-Targeted CAR-T trial (Mailankody et al. NEJM Sept 2022) and any key differences compared to the BCMA directed products?
I think it is hard to draw too many conclusions given that this is a first in human phase I study with only a small number of patients. What is promising here is that GPRC5D seems to be a good target for myeloma, even among patients with prior exposure to BCMA-targeted therapy. The population in thi...
Should immune checkpoint inhibitor be held for palliative RT to bladder in patient with metastatic urothelial carcinoma who has stable systemic disease on immunotherapy?
I assume the scenario applies to patients with good systemic disease control on immune checkpoint inhibitor (ICI) but with symptomatic primary tumor of the bladder, e.g. hematuria, pain, and obstruction. It is helpful to have a good discussion between Med Onc & Rad Onc regarding the optimal timing, ...
What is your approach and preferred first line treatment regimen for advanced/metastatic adenosquamous NSCLC?
As with all advanced lung cancer, the answer to this question depends upon molecular characteristics and PDL1 status. I would perform NGS (next generation sequencing) analysis of all adenosquamous cancers (by tissue, and if uninformative, potentially ctDNA testing) as well as PDL1. As I tell all of ...
How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?
I would do my best to minimize immunosuppression. I would use IL-6 or Abatacept and possibly rituximab. Have done all to minimize DMARDs and have had success with all 3.
What are your recommendations regarding sexual activity for a couple when one of them is diagnosed with a HPV-positive oropharyngeal cancer?
We always counsel patients regarding the etiology of HPV if they have a p16+ tumor. We tell them that this is an infection most likely acquired through sexual activity and that the latency period is approximately 20 years from the time of exposure until the time of a cancer diagnosis. We note that o...
How would treat a patient with good performance status with PTCL-NOS found to have leptomeningeal disease during treatment course with CHOEP?
I haven’t combined CHOEP with high dose methotrexate before! I have treated a patient with HIV-associated B-cell lymphoma with R-EPOCH and high dose methotrexate at D15 successfully with growth factor support. For patients with PTCL-NOS and leptomeningeal involvement at presentation, I would likely ...