Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Which types of pancreatic cancer patients should we consider sending to a center that offers EUS-guided Radiofrequency Ablation (RFA) therapy?
EUS-guided ablation for appropriately selected mucinous pancreatic cysts and, to some degree, neuroendocrine tumors is becoming increasingly standardized with multiple reviews on the subject. (Rodger et al., Techniques and Innovations in Gastrointestinal Endoscopy 2024, Moyer & Canakis, PMID 3879629...
What is your management approach for CAR-T induced motor neurologic deficits (cyclophosphamide/IVIG/steroids, etc.) and any prophylactic approach to an early, rapid rise in absolute lymphocyte count post CAR-T infusion?
Specifically, this seems to be a question around cilta-cel. There has been some recent guidance to consider pre-emptively starting dexamethasone if the absolute lymphocyte count rises above 3,000 in the period following CAR T administration. This partially stems from the observation that many of the...
What is your approach to IV fluid management for the treatment of hypercalcemia of malignancy?
At this point, I believe one can use either saline or lactated Ringer's. There is some evidence that low-chloride-containing solutions have advantages in general, which may well be the case, but we need more data on that. The amount of calcium in LR is very small and should not make a difference (1....
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
If an asymptomatic patient requires a delay up to a week before starting chemotherapy for Stage III lung cancer, do you also push back the radiation start date?
Typically, the reason for B12 and folate prior to chemotherapy is related to the drug that will be used, pemetrexed. Giving the premedication reduces hematologic and gastrointestinal toxicity to tolerable levels. One week typically will not make a difference and I would usually wait to start. Howeve...
What factors do you take into account when deciding which gene expression assay to utilize when making adjuvant treatment decisions in patients with non-metastatic breast cancer?
Oncotype DX has been validated in multiple large prospective trials and has demonstrated predictive value, while MammaPrint has not been validated to be predictive for chemotherapy benefit but only identifies low-risk biology. Oncotype DX has been validated in node-negative and 1–3 node-positive dis...
Would you consider adding adjuvant ribociclib for a patient who has already received 2 years of endocrine therapy and is eligible for ribociclib according to the NATALEE trial?
Since the NATALEE trial excluded patients who received more than 12 months of neoadjuvant or adjuvant endocrine therapy, I would probably not consider ribociclib for your patient, as she is too far out from initiation of endocrine therapy.
What is your preferred neoadjuvant chemotherapy regimen for borderline resectable pancreatic ductal adenocarcinoma?
Agree while guidelines for the use of adjuvant therapy in resected PDAC are stronger (6 mos therapy for T1N0 tumors or greater), those for the use of neoadjuvant therapy are less clear. Some guidelines recommend not to use NAT unless there is a radiographic interface with mesenteric vessels, or in t...
Given the FAST and FAST-Forward trial data, can we consider those ultra-hypofractionated whole breast radiation schemes to be standard of care for early-stage breast cancer?
With respect to FAST (28.5 Gy in 5 fx over 5 weeks), it can be considered based on 10-year data. Local control rates were low in all arms, but in general, I limit this to patients who can't do standard hypofractionated WBI (40/15).FAST-Forward now has 10-year outcomes and can be considered for appro...
Does the possibility of future Lu-177–PSMA therapy change your current threshold to offer earlier metastasis-directed RT in oligometastatic prostate cancer?
There is a lot of excellent research being done on the efficacy and tolerance of combined Lu-177-PSMA therapy and EBRT. So far, the combination is well tolerated, and there is some data that sequencing the two to allow EBRT to treat the more “Pluvicto-resistant” lesions may help with efficacy.The qu...