Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Among the many assays/tests available for "liquid biopsies" in metastatic NSCLC, are there any situations where you would want to use one specific assay over the others?
There are many commercial and academic assays under development. None are approved at the moment and none have been shown to be superior. Use of a well reported commercial assay with whom your institution has experience is reasonable
How do you approach colon cancer chemotherapy in a patient who has had documented coronary vasospasm with FOLFOX?
Although there are case reports of successful rechallenging with infusional 5-FU in the setting of calcium channel blocker treatment, I don't endorse this approach given the potential cardiac consequences. Capecitabine is not an appropriate alternative since it's just infusional 5-FU in a different ...
How do you approach small lymphocytic lymphoma that does not have a leukemic phase?
Patients with SLL very often (90-95%) have circulating tumor cells in the blood that are CD19, CD20, CD5, CD23, sig dim by flow consistent with CLL tumor cells. If not in the blood, these same cells evevn more often can be found in the bone marrow. If disease is in either site with nodal involvement...
What would you choose as a first line therapy for a patient with CLL who is asymptomatic with Rai Stage 4 with bulky adenopathy and organomegaly?
A big discriminating feature here would be based upon age. For a patient who is fit and <65-70 years, IGHV mutated disease may be curable with fludarabine, cyclophosphamde, and rituximab therapy, first piloted by Michael Keating's group at MD Anderson Cancer Center. At a median follow up time period...
What is your approach to young healthy women with locally advanced breast cancer and biopsy-proven low cervical lymph nodes?
At this point, we treat them with definitive intent as most often these low cervical nodes are level 4 or adjoining level 5 node which by definition are supraclavicular nodes (often radiologists call them as cervical nodes but one needs to see images to confirm location). A subset of patients with t...
How do you counsel a woman regarding her previous hormonal contraception and the risks with her newly diagnosed invasive breast cancer?
I believe the risk of breast cancer from the use of hormonal contraception is very small, in the absence of other contributing risk factors such as family history.A recent 2017 NEJM article (Morch et al) assessed the associations in a large cohort of 1.8 million women in Denmark followed for > 10 ye...
Would you consider upfront chemoradiation therapy for a patient with metastatic anal squamous cell carcinoma if they have a large burden of disease at the anus?
There aren't many good systemic options for metastatic squamous cell carcinoma of the anus. In cases of significant local symptoms, I plan a definitive treatment using definitive dose with 5FU and cisplatin (mitomycin C may also be acceptable). This way, I have the option of giving full dose but the...
Beyond PD-L1, when would you consider additional molecular testing (EGFR, ALK1, ROS1) for patients with squamous cell lung cancers?
I mainly test patients with squamous cell lung cancer if they are never, remote or light smokers, or if the diagnosis was based on a small biopsy and pathologist was not 100% sure squamous cell was the histology. Other experts would argue to test all patients regardless of histology for mutations as...
What is your approach to treating early stage EBV-positive diffuse large B-cell lymphoma of the elderly after a CR to systemic therapy?
EBV+ diffuse large B-cell lymphoma of the elderly, which typically affects apparently immunocompetant individuals > 50 y/o, was a provisional diagnosis in the 2008 edition of the WHO classification system. EBV+ DLBCL has been recognized in younger patients which led to a revision in the 2016 classif...
Do you use absolute WBC count or doubling time to determine whether to start treatment for early stage CLL?
In my view, the pace of disease is a more relevant indicator of the need for treatment than any absolute WBC count. Observations over time usually make it clear when treatment is needed. Several studies have shown that early intervention is not associated with improved survival, though it must be ac...