Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach patients with early stage resected melanoma (Stage IIA) for adjuvant treatment?
The current guidelines do not recommend adjuvant treatment for patients with stage I/IIA disease outside the setting of a clinical trial. Major trials including the KEYNOTE-054 and CheckMate 238 have excluded patients with early stage I/IIA disease. However, in patients with stage IIB/IIC disease ad...
How would you approach a patient with clinical T3N1 anorectal malignant melanoma referred by a surgeon for neoadjuvant therapy?
Anorectal malignant melanoma is quite rare and only <1 percent of all anorectal cancer are mucosal melanoma (Cagir et al., PMID 10496563) Patients with newly diagnosed anorectal malignant melanoma should undergo HIV screening since HIV infection is considered to be one of the main risk factors (Cagi...
What is your approach to systemic treatment of de novo metastatic hormone-sensitive prostate ductal adenocarcinoma with lung only metastases?
Nearly all patients with mHSPC/mCSPC deserve combination therapy based on multiple phase III clinical trials. There are very few exceptions to this. Even frail patients should be considered for intensified therapy since the published data suggests minimal to no worsening in HRQoL over ADT monotherap...
Would you ever consider managing HR+ DCIS non-surgically?
In the wake of the COVID-19 pandemic, I think we've all gained experience managing early stage (0-1) HR+ breast cancers with endocrine therapy as a stop-gap until surgery was possible. However, outside of a clinical trial or unusual circumstances, I would not normally consider managing HR+ DCIS non-...
Can CAR T cell therapy be considered for heart transplant recipients with concurrent lymphoproliferative disorders?
The short version of my answer is: Possibly Yes. There is a very limited evidence from the literature in this topic, however, I will base my explanation on the following case reports: McKenna et l., PMID 37129856, Dang et al., PMID 33002249, Portuguese et al., PMID 36575360.The provided case reports...
Is a bone marrow biopsy necessary in a patient with a previous tissue diagnosis of plasmacytoma or smoldering multiple myeloma, who now meets criteria for active myeloma?
It depends. If it is a solitary plasmacytoma with no other lesions, a bone marrow biopsy would offer 2 things: (1) if there is bone marrow involvement, you know that systemic therapy is needed and it is not a solitary plasmacytoma and (2) if you can not get a myeloma FISH panel on the plasmacytoma b...
How do you approach patients with a new primary melanoma, not an in-transit metastasis, while on adjuvant immunotherapy/treatment for a previous melanoma lesion?
This is tough because of the paucity of data to answer the question. In my practice, I recommend patients who develop a new primary melanoma undergo standard-of-care therapy for the new melanoma (e.g., WLE +/- SLNB).
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...