Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What scenarios do you utilize CT venography in the workup of suspected DVT?
There are likely a limited number of scenarios in which a CT venogram should be ordered. My own approach is as follows: Bilateral deep venous thrombosis: to exclude IVC obstruction. Anecdotally, in the younger patients, we have made a diagnosis of IVC atresia. Suspected May-Thurner syndrome: typica...
What scenarios do you utilize CT venography in the workup of suspected DVT?
There are likely a limited number of scenarios in which a CT venogram should be ordered. My own approach is as follows: Bilateral deep venous thrombosis: to exclude IVC obstruction. Anecdotally, in the younger patients, we have made a diagnosis of IVC atresia. Suspected May-Thurner syndrome: typica...
How would you sequence treatment (chemo and chemoRT) for a patient with a very symptomatic locally advanced rectal adenocarcinoma, MSS, with involved pelvic nodes and a mass abutting the sphincter, with no distant disease on CT but marked elevation in CEA above 300?
A pretreatment CEA level above 300 ng/mL is far beyond the typical range seen in stage II–III disease and warrants aggressive investigation. PET/CT should be strongly considered in this case to exclude occult distant disease, as it can change management in 8–11% of patients and is specifically recom...
How do you approach managing depression symptoms in patients who have had repeated high risk of bleeding?
Overall, evidence suggests that while SSRIs do increase the risk of bleeding. The absolute risk of a bleeding event remains low and is usually not serious. A 2017 meta-analysis by Laporte et al., suggested that overall bleeding risk is increased by at least 36% while other meta-analyses suggest that...
What are the main limitations or barriers to integrating gene expression profiling into routine melanoma management in your practice?
There have been about 250,000 tests done in the country. Around 40% of melanomas each year are tested, and somewhere around 10,000 to 11,000 doctors use it, so access has not been much of a barrier. As far as cost goes, everything has a cost, though patients do not pay for it. If the insurance compa...
What should be the first line treatment for metastatic uveal melanoma?
There is no consensus for frontline treatment of metastatic uveal melanoma. A clinical trial would be recommended for all patients if possible. If the disease is only within the liver, consideration of liver directed therapy would be reasonable. For metastatic disease beyond the liver checkpoint imm...
What are your practical considerations for incorporating bispecific antibody therapy into treatment of relapsed DLBCL?
In relapsed/refractory DLBCL, if the patient has not yet received bispecific antibody (BsAb) and/or CAR T-cells, and the patient is eligible and able to receive CAR T-cells, I favor CAR T-cells before BsAb, given extensive follow-up time demonstrating CAR T-cells are a potentially curative approach ...
How do you approach Tarlatamab use in an elderly patient with relapsed ES SCLC?
Age is relative and there are numerous studies showing that well-performing elderly patients can tolerate systemic therapy to small cell lung cancer. That being said, I first assess whether additional cancer therapy is within the goals of care for each individual patient. While the outcomes for DLL3...
When will you choose Tarlatamab over an alternative systemic therapy (e.g. lurbinectedin, topotecan) for relapsed ES SCLC?
I generally offer tarlatamab as a second line option in small cell lung cancer patients who are fit (ECOG 0-1), can logistically accommodate the hospitalization and infusion schedule, have low-risk factors for ICANS, and have treated brain metastases. I would consider a platinum etoposide rechalleng...
Would you consider delaying tarlatamab initiation in a patient with ES SCLC who recently completed RT for CNS disease, given the concern for immune effector cell-associated neurotoxicity syndrome (ICANS)?
I would not delay beyond what we already do for other systemic treatments. We tend to wait at least a week or more after whole brain RT and systemic therapy of any nature. I do not think this is any different.