Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you offer PCI to a patient with LS-SCLC, who presented initially with paraneoplastic syndrome (encephalomyelitis), but had no neurocognitive sequelae after chemoradiation?
I am not a big fan of PCI. I think the term itself is a misnomer. PCI trials in LS-SCLC were conducted in an era when MRI brains were not performed.Let's look at the "outdated" data that all of us, including NCCN, quote. A meta-analysis conducted by Auperin and colleagues demonstrated a 5.4% 3-year ...
For patients on a bone-modifying agent for osteoporosis/severe osteopenia in the context of adjuvant AI therapy, how do you manage the bone-modifying agent once their AI course is complete?
In this case, I would be guided by the bone density (DXA) scan, if there is still osteoporosis or severe osteopenia, I would continue the BMA and repeat the DXA scan in one or two years. If the DXA shows improvement, I would discontinue the BMA, knowing that one can re-institute at a later date. Sev...
How do you workup erythrocytosis with a normal or elevated serum erythropoietin?
First, I would consider using the term erythrocytosis rather than polycythemia. Too often, use of the term polycythemia may suggest polycythemia vera (PV) (a malignancy) rather than something more benign.The recommended up front testing in the evaluation of erythrocytosis consists of up front JAK2V6...
How do you approach a patient with good PS and no treatment contraindications who has progressed on a RET inhibitor for NSCLC?
The management approach will be similar to how we approach patients receiving targeted therapy, i.e. oligoprogression vs widespread progression. Multimodality approaches with surgery or radiation to consolidate residual disease or oligoprogressing sites may enable patient to remain on the same targe...
How do you manage end-organ toxicity such as hepatotoxicity or pulmonary toxicity in a patient receiving RET-inhibitors for NSCLC?
For liver toxicity, I would hold the TKI for grade 3 of higher elevations in the transaminases, and monitor 3-5 days thereafter and then weekly. If the LFTs resolve, I would resume the TKI at a dose reduction. If the LFTS remain normal a couple weeks after resolution, I might even consider dose re-e...
Is there any benefit in continuing VRd instead of VR as maintenance therapy in transplant ineligible multiple myeloma?
I love this question - mostly because it makes me think of just one study, but really, I'm excited to hear what others have to say. I always think of RV-MM-PI-0752 (ASH 2018) studying the efficacy and feasibility of dose/schedule adjusted Rd-R vs continuous Rd in elderly and intermediate-fit newly d...
For persistent localized muscle-invasive bladder cancer following chemoradiation in patients who are not surgical candidates, what is an appropriate next therapy?
For this situation, optimal therapy is unclear. However, assuming the patient did not achieve clinical CR or recurred within a year, following maximal TURBT (which can achieve remissions in up to 15% of untreated patients), systemic therapy may be considered while tailoring therapy based on previous...
How do you counsel patients who are candidates for a clinical trial regarding their options?
I typically discuss the option with patients as early as possible in their diagnosis, and explain that at some point during their treatment they may become a candidate for a clinical trial. I discuss resources to look into clinical trials and what they mean for patients. We discuss patient website r...
When might you recommend adjuvant chemotherapy for fully staged/resected stage IA clear cell ovarian carcinoma?
Clear cell carcinoma of the ovary is one of the less common forms of ovarian cancer and is considered a high-grade tumor. It has a higher risk for recurrence and a poorer prognosis as compared to some other forms of ovarian cancer. For that reason, adjuvant therapy with platinum based chemotherapy i...
When would you ever choose cisplatin over carboplatin in extensive stage small cell lung cancer?
I prefer carboplatin over cisplatin in ES SCLC as there does not seem to be proven benefit and there is certainly higher risk for toxicity. There was a recent report at ASCO with similar findings. I reserve cisplatin for limited stage disease with concurrent radiation or as adjuvant therapy in cases...