Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there an equivalent test for serum viscosity in sickle cell disease?
I would not typically order serum viscosity outside of the setting of paraproteinemia. In that setting, I still think serum viscosity is useful, especially as opposed to plasma viscosity, which might be elevated in a sickle cell patient due to the acute phase reactant fibrinogen. It is true also th...
How do you utilize serum viscosity in the clinical management of plasma cell disorders?
In brief, I discourage checking serum viscosity in almost all cases. Why? Hyperviscosity syndrome is a clinical diagnosis. If IgG >7000 mg/dL, IgA > 5000 mg/dL, or IgM > 3000 mg/dL, and the patient has symptoms of hyperviscosity (altered mentation, shortness of breath, tinnitus, mucosal bleeding, e...
Is there a role for reassessing somatic mutation status at relapse in patients with epithelial ovarian cancer?
No – I don’t think there is any role for reassessment at this point. If commercialization of testing for reversion mutations becomes available – and it will or a functional test of HR status – then yes – I would reassess but I don’t see a reason at this point.
How would you treat non-secretory myeloma in an inpatient setting?
This entity is rare with the use of free light chain assay. About 2% of all cases are non-secretory. In A Greek study, they were younger, less anemic, and had less often renal dysfunction and less extensive bone marrow infiltration. Presence and extent of bone disease were similar, however, hypercal...
How does clinical intramammary lymph node involvement in HER2+ breast cancer affect your neoadjuvant chemotherapy choice?
The AJCC 8th edition classifies an intramammary node as an axillary node (1). Intramammary nodes are associated with axillary involvement although their independent contribution to recurrence risk remains controversial. Accordingly, I would recommend neoadjuvant TCHP in this case (I drop carboplatin...
How do you manage a HR-/HER2+ breast cancer patient with local progression during neoadjuvant TCHP?
With the robust activity of HER2-targeted agents in the operable setting, this is a highly concerning clinical scenario. I would retest for HER2 on the biopsy specimen and confirm its positivity. Also, I have significantly limited the use of anthracyclines in patients with HER2+ breast cancer - give...
For patients with RET-fusion+ NSCLC who progress on RET inhibitors, do you repeat tumor molecular profiling before selecting subsequent therapy?
Yes, I repeat molecular profiling, ideally with both repeat tissue and liquid biopsy.
Do you offer adjuvant androgen deprivation therapy for AR+ salivary ductal carcinomas treated with curative intent?
There is a recently released ASCO guideline [Geiger et al., PMID 33900808] which specifically addresses the role of systemic therapy in the management of salivary gland malignancies.Regarding systemic therapy, the recent ASCO guideline suggests concurrent chemotherapy, HER2-Neu targeted therapies, a...
What is your preferred 3rd line therapy for patients with metastatic sarcomatoid RCC?
There is no standard 3rd line therapy for sarcomatoid RCC. We know from gene expression data and clinical trials that sarcomatoid RCC tend to be more responsive to immune therapy than VEGF-targeted therapy, so I would be tempted to find a clinical trial with a novel IO agent. If unavailable, one cou...
How do you manage endocrine therapy in patients on tamoxifen who develop thrombophlebitis but not DVT?
In a patient on tamoxifen, the risk of clot extension into the deep system is higher than average. In such scenarios, the recommendation is to use anticoagulation for at least 6 weeks (consider 3 months if no improvement noted at 6 weeks). Tamoxifen should be held for the first 3 weeks, consider res...