Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Have the 10-year results from UK FAST-Forward impacted your practice with regard to patient selection?
I would consider our practice at Mayo as early adopters of ultra-hypofractionation for breast, largely driven by similar institutional trials for shorter courses and the patients we care for. As a result, we have pretty routinely offered 26 Gy/5 fraction whole breast RT since the 5-year follow-up wa...
Similar to the HFA-ICOS risk stratification tool for patients on chemotherapy, are there cardiac risk calculators available for use in patients starting immunotherapy?
No, there are no cardiac risk calculators for patients starting on immune checkpoint inhibitors (ICI). This is primarily because, aside from the use of dual immune checkpoint inhibitor therapy, we have not identified risk factors for ICI-induced myocarditis (Mahmood et al., PMID 29567210). Prior to ...
Would you offer first line atezolizumab plus bevacizumab in unresectable/metastatic hepatocellular carcinoma based on the IMbrave 150 data?
I would definitely discuss (and offer) atezolizumab/bevacizumab as first-line therapy for advanced HCC and in fact, I have already started the treatment in 3 patients. There is no denying that this is the greatest advance in first-line therapy since the presentation/publication of the SHARP trial an...
How do gene expression profiling results influence your recommendations for surveillance intensity in patients with early-stage melanoma?
Gene expression profiling (GEP) defines surveillance intensity for early-stage melanoma. Early-stage melanoma (i.e., stage I) would not typically be expected to metastasize or recur. Patients at high genomic risk of recurrence should be surveilled more closely, including self-skin exams in between r...
How do gene expression profiling results impact your decisions regarding adjuvant therapy in node-negative or borderline-risk melanoma patients?
Node-negative patients comprise a majority of bad outcomes from melanoma deaths. These are the patients that I worry about the most, and 90% or so of lymph node biopsies are negative. High-risk DecisionDx-Melanoma (DDx-M) scores allow for routine serial imaging despite a negative lymph node biopsy. ...
Do you get DEXA scans routinely before starting ADT for prostate cancer or endocrine therapy for breast cancer?
When initiating long-term ADT, I order a DEXA scan, check vitamin D level, ensure adequate dietary calcium intake, and discuss weight-bearing exercise/refer to PT when appropriate. I also continue check DEXAs every 2 years unless they otherwise meet criteria for a bone-modifying agent (mCRPC with bo...
Is there benefit to aggressively treating hemochromatosis in a patient who has already progressed to cirrhosis at the time of diagnosis?
The short answer is yes, there is a benefit to treating iron overload in a patient with hereditary hemochromatosis (HH) with cirrhosis. HH involves at least five mutations, most commonly in the HFE gene (common variants include C282Y and H63D), leading to hyperabsorption of iron and progressive accu...
For patients on immune checkpoint inhibitors presenting with chest pain, dyspnea, fatigue, and troponin elevation, would you recommend early initiation of high dose steroids for empiric treatment of ICI myocarditis while pursuing workup with coronary angiogram, echocardiogram, and/or cardiac MRI, or wait until alternative etiologies have been ruled out?
This question raises an important point that the clinical presentation of ICI-associated myocarditis often overlaps with other cardiovascular disorders, including acute coronary syndrome, chronic CAD, congestive heart failure, and other nonischemic cardiomyopathies. Therefore, prompt initiation of w...
Should all patients with a remote history of immunotherapy, chemotherapy and/or radiation therapy have a baseline TTE regardless of ASCVD risk?
The current ASCVD risk assessment calculators we have available do not contain cancer-specific parameters and thus are inadequate for accurate assessment of a cancer survivor's risk of developing CHF and ischemic heart disease. If patients have received mediastinal radiation therapy or high-dose ant...
Given recent studies investigating ICI myocarditis biomarkers such as Temra CD8+ cells, is there now a growing selection of clinical biomarkers, besides BNP and troponin, being measured routinely in ICI myocarditis cases?
Since novel biomarkers are not yet clinically available in most practice settings, these are not yet routinely being checked though they certainly merit further investigation for diagnosis of ICI myocarditis. Currently, recommended biomarkers include indicators of cardiac injury (troponin, BNP or NT...