Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How are you approaching endocrine therapy for patients with metastatic HR+/HER2+ breast cancer in light of enhanced HER2 directed treatment with either T-DXd/pertuzumab or HP/tucatinib?
This is an area without clear data. I am not entirely sure that it matters. While the S8814 trial demonstrated that sequential chemotherapy followed by endocrine therapy (tamoxifen) was the best arm, this question has not been fully addressed with aromatase inhibitors. I typically would start ET wit...
What would you offer as adjuvant therapy for a resected stage IIIB adeno NSCLC in a patient who refuses chemotherapy?
Patients with stage III NSCLC are at very high risk for recurrence, and in this situation, I would make sure that your discussions with the patient highlight this clearly. My usual thought is that if a patient can tolerate and recover from lobectomy/resection, then that is a reasonable indication th...
How do you interpret isolated PSMA-avid sites in a patient with prostate cancer with no pelvic or RP LN uptake?
The issue of false-positive PSMA scans is a vexed one, and we are still learning how to handle this optimally. My general approach is to think about the clinical context, level of risk, and whether an early diagnostic pick-up will actually make a clinical difference. For example, in a patient with ...
How do you choose between neoadjuvant and adjuvant chemo-immunotherapy for patients with resectable stage II-IIIA NSCLC?
The billion dollar question. For patients with resectable stage II-IIIA NSCLC, how do you choose between neoadjuvant and adjuvant chemo-immunotherapy in light of the recent FDA approval of the CheckMate-816 regimen? Of course, this approval quickly followed in the footsteps of the FDA approval of at...
What is your preferred comprehensive nodal irradiation approach in non-metastatic breast cancer patients with underlying respiratory diseases or poor baseline respiratory function in light of the findings from the RadComp Trial?
The RadComp trial PRO-CTCAE item for no shortness of breath versus any shortness of breath significantly favored protons as reported in the abstract. However, after correction for multiplicity, this became non-significant, meaning there was no difference. While multiplicity analyses ensure that fals...
What is a reasonable hemoglobin goal for patients with chronic anemia presenting with acute MI?
The diversity of acute myocardial infarction (AMI) does not allow a monolithic answer to this question. The recent MINT study—an important contribution presented at AHA 2023 and published in NEJM—highlights this complexity. Although MINT, which randomized anemic patients with AMI to liberal versus r...
Would you continue or stop anticoagulation for a DVT/PE in a patient with active cancer who has completed 6 months of therapy?
This is an important question that we didn’t really have a clear answer for… until this year when an NEJM RCT was published! Mahé et al., PMID 40162636 In this RCT, patients with cancer-associated VTE who completed 6 months of full-dose apixaban were randomized to half-dose apixaban vs. full-dos...
Do you diagnose MCAS if a patient is concurrently on drugs known to cause non-specific mast cell degranulation?
Yes, MCAS may be diagnosed if a patient is on drugs known to cause non-specific mast cell activation.The reason for this answer requires a better understanding of MCAS criteria and etiology. In 2022, an expert consortium proposed revisions to the classification of mast cell activation disorders. (Va...
Do you offer fertility preservation to patients prior to CAR-T therapy?
There is no evidence yet about the impact of CAR-T itself on fertility, and this will be difficult to study in isolation in this population. Many CAR-T patients have been heavily pre-treated, so semen cryopreservation and oocyte harvesting may not be successful; but if feasible they should be attemp...
How do you manage patients desiring home hospice but with severe thrombocytopenia and/or anemia due to advanced malignancy?
As a pediatric hematologist/oncologist and pediatric palliative care physician, I can only speak to our approach with children, which may be quite different than the adult world. In our community, we are not able to provide blood or platelet transfusions in the home. For children who are profoundly ...