Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach pathologic review and genomic testing, if indicated, of a spindle cell neoplasm?
Experienced sarcoma pathologists should review cases such as this. The rate of a change in diagnosis upon pathology review at a sarcoma center, after an initial review by a general pathologist, is surprisingly high (Ray-Coquard et al 2012, Annals Oncol). Unless there is a specific diagnostic concern...
How do you interpret recent large retrospective analyses comparing radical prostatectomy vs. radiation for prostate cancer?
There have been numerous comparisons of RT vs. RP from a variety of study teams with various conclusions, and it often seems like the principal conclusion of the study is best predicted by the subspecialty from which the authors originated (urology vs. radiation oncology). As the question partially ...
For gross hematuria from a primary bladder tumor, what palliative radiation regimen would you recommend?
I found that 36 Gy/6 Fx delivered weekly is a great option for palliation.This has been used in curative system, as well, but I find it to be particularly helpful in elderly patients or those with travel issues. There is a phase 2 study in patients who are medically inoperable and the local control ...
How do you treat non-spine bone oligometastases?
Get the MRI. It is proven to reduce inter-observer variability in contouring (Raman et al., PMID 29748100). More philosophically, sometimes you'll see something more, sometimes you won't. But the only way to know is to check. And if this treatment is worth doing, it's worth doing accurately -- espe...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What is your approach to the management of chronic GI bleeding from AVMs in an elderly patient on DOAC for atrial fibrillation?
I would definitely strongly consider the left atrial appendage occlusion device in these patients. While usually these devices (such as Watchman) do require anticoagulation for about 45 days until the device has an endothelial layer form on it (we usually confirm with a CT scan or TEE), there are so...
Would you withhold immunotherapy for ES-SCLC during the COVID-19 pandemic?
Risks of COVID-19 infection and severe pneumonia seem to be higher in our patients with lung cancer. This is fairly early data and some of the patients included in those analyses were not receiving any active therapy. This suggests that at least some of the risk is simply frequent visits to the canc...
In pediatric patients with Hodgkin lymphoma who have a partial response after chemotherapy and multiple disease sites above and below the diaphragm, how do you approach radiotherapy planning considering cumulative dose and toxicity?
RT dose and target volume in pediatric Hodgkin lymphoma are determined according to the systemic therapy protocol being used. For example, your case suggests a patient with Stage III or IV disease. In the COG study AHOD1331, patients received either Bv-AVE-PC or ABVE-PC systemic therapy x 5 cycles a...
How would you manage a patient with family history of protein S deficiency, now with provoked VTE and low protein S?
Low protein S would need to be checked at the appropriate time. It should not be checked during acute thrombosis It should not be checked while the patient is on DOAC If the provoking factor was estrogen containing contraceptives, testing should not be performed until the patient has been off of est...
For transplant-ineligible aplastic anemia planned for immunosuppression, how do you approach duration and tapering of cyclosporine and eltrombopag?
One of the most common mistakes in the management of AA is premature tapering of cyclosporine or tacrolimus. If there is a complete remission, and by that I mean normalization of counts, not complete remission as defined in some papers (e.g., ANC 1000, Plts 100,000, Hb 10 as in de Latour et al., PMI...