Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you include HER2 directed therapy in the treatment of HER2+ small bowel adenocarcinoma?
I have not encountered any HER2-positive small bowel carcinoma but would consider, it will be reasonable to use HER2-targeted treatment in later line setting (after oxaliplatin/irinotecan-based chemo). There is very limited data and possibly the only study with this population would be in the MyPath...
Would you use adjuvant pembrolizumab for bilateral ccRCC with R1 resection?
It would depend on the pathology of each resected tumor, but my initial thought is that I would not. My concern would be that renal function is likely reduced and nephritis (although rare) could have significant consequences. Certainly, genetic counseling should be considered for all bilateral tumor...
How do you approach the discussion with a patient who is seeking proton therapy for early stage breast cancer?
I would ask why they want protons. Assuming they give the expected answer, I would say something like this: “Thanks for asking about that. I certainly understand why you might feel as if protons would be better for you. I understand that receiving radiation can be scary, and indeed, radiation can be...
Should patients with co-existing moderate-severe valvular disease (particularly AS and MS) and malignancy requiring radiation therapy undergo more frequent surveillance surface echocardiograms?
The answer is yes, for some patients with baseline moderate to severe valvular heart disease receiving radiation, with the heart in the radiation field (i.e. left breast, lung, esophageal cancers), they should have more frequent surveillance echocardiograms.The 2020 ACC/AHA valve guidelines recommen...
How would you treat a metastatic pure urethral adenocarinoma?
The treatment of rare or unusual urologic tract tumors remains an area of active investigation to optimize approaches. In general, most practitioners would utilize a GI malignancy-focused regimen for a metastatic urothelial tract pure adenocarcinoma (mucinous/or enteric type) such as FolFox off of a...
What is your preferred first line approach to patients with Stage IV non-squamous NSCLC with good performance status, no driver mutations, PD-L1 low-positive, and CKD IIIB or worse, CrCl < 45 mL/min?
This is a common scenario. For patients with PD-L1 high tumors, would certainly, of course, feel comfortable with ICI monotherapy. For squamous NSCLC with PD-L1 low or negative, the question is more straightforward since taxane can be given in the setting of renal insufficiency. For nonsquamous NSCL...
Do you recommend continued PCR testing in a CML patient who underwent allogeneic stem cell transplantation with an identical match about 20 years ago?
If the patient was transplanted in chronic phase and has not experienced relapse post alloSCT nor h/o BCR-ABL1 Q-PCR/FISH positivity post alloSCT, I do not believe that there is much value for continuous PCR testing 20 years later as the vast majority of the relapses occur the 1st few years post all...
What chemotherapy regimen would you use for a woman with pre-existing neuropathy causing imbalance, who now has a T1N0 ER+ and Her2+ breast cancer?
If the tumor is T1c, you can consider AC x4. Afterwards, single-agent Herceptin could be considered.
How would you treat a patient with a locally recurrent myxofibrosarcoma, FNCLCC grade 2, that has recurred after multiple resections and radiotherapy?
Depending on age, PS, organ function, etc. doxorubicin-based chemotherapy remains the standard of care systemic therapy option. A clinical trial exploring check-point inhibitor/s is a very reasonable choice given preliminary data. The hope/goal here would be to find an effective (neo)adjuvant option...
How would you approach a patient with solitary plasmacytoma with an FLC ratio >100, but a negative bone marrow biopsy and negative PET-CT?
Are we to assume the Ca, Hgb, and creatinine are normal? Completing the testing with 24 hr UPEP with immunofixation is important. With a free light chain ratio of >100, there is generally proteinuria. If 24 hr urine total protein is 1 g/day or more, I would do a kidney biopsy to document light chain...