Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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...
How should PARP inhibitors be incorporated into clinical practice in later line/maintenance of platinum-sensitive ovarian cancer for PARP inhibitor-naïve patients?
Personally, if I have a PARPi naïve recurrent platinum-sensitive patient, I would have no hesitation in treating them as we did in these trials. The OS data and FDA action on the prior indications, in my opinion, was a reckless statistical exercise and potentially harmful to patients.
What outcome data do you view as most impactful to make treatment decisions regarding the use of PARP inhibitors in later line or recurrent ovarian cancer?
The crossover makes the OS data very hard, if not impossible, to interpret. The findings were not that parps for platinum sensitive maintenance for non-BRCAm were detrimental -- it was that they did not seem to show OS benefit. Certainly, treatment free intervals and quality of life are extremely im...
Would you use the MIPSS-PV risk scoring to decide in decision making for cytoreductive therapy in PV?
I think the MIPSS-PV is helpful in understanding predicted overall survival and appreciating the risk of progression, the decision to cytoreduce is still routed in the classic thrombosis risk model of age plus thrombosis history. I would certainly recommend getting an NGS panel to better understand ...