Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Similar to the HFA-ICOS risk stratification tool for patients on chemotherapy, are there cardiac risk calculators available for use in patients starting immunotherapy?
No, there are no cardiac risk calculators for patients starting on immune checkpoint inhibitors (ICI). This is primarily because, aside from the use of dual immune checkpoint inhibitor therapy, we have not identified risk factors for ICI-induced myocarditis (Mahmood et al., PMID 29567210). Prior to ...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
I emphasize that the reference range intentionally excludes normal individuals who are a little different from the average person, and that the reference range is just a numerical exercise and general guidance, not something that was ordained by higher powers. I don't use the analogy for patients, b...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
I emphasize that the reference range intentionally excludes normal individuals who are a little different from the average person, and that the reference range is just a numerical exercise and general guidance, not something that was ordained by higher powers. I don't use the analogy for patients, b...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
For atrial fibrillation patients with high risk of CVA who cannot tolerate full dose AC due to bleeding, do you consider low dose/extended dosing anticoagulation even if they do not meet age/GFR criteria for a dose reduction, if Watchman is not readily available as an option?
Most drugs, including anticoagulants, have a dose-response. Therefore, one could argue that even though DOACs were not studied at low doses, except in defined sub-groups such as the very elderly, using such a dose in other situations may have some benefit. The problem is that without data, we simply...
How would you approach the treatment of low grade, stage IA, triple negative apocrine adenocarcinoma of the breast in a female patient in her 70s?
I would not treat this the way I would a typical triple-negative breast cancer, since the risk of distant recurrence from occult metastatic disease is low. Assuming she had breast-conserving surgery, radiation, favoring partial breast, is reasonable. In terms of systemic therapy, if the cancer in th...
Do you consider estrogen patches in treatment of prostate cancer?
Oral estrogenic formulation (such as DES) was historically used for androgen suppression in prostate cancer patients. This was based on the principle that estrogen decreased serum testosterone levels by suppressing luteinizing hormone production through a negative feedback loop on the hypothalamus a...
Which patients, if any, do you offer transdermal estradiol as a method of ADT instead of LHRH agonists?
My default form of ADT remains a GnRH agonist or antagonist but estradiol transdermal patches are clearly effective and safe as an alternative option for men who either 1) have significant loss of bone density/osteoporosis, 2) have significant hot flashes with traditional ADT and wish to try an alte...
Should cisplatin, gemcitabine, and veliparib be the standard of care in treating metastatic/unresectable pancreatic cancer with BRCA or PALB2 mutation?
In a recent publication (O’Reilly et al. JCO 2020), the authors reported high response rates (74.1% vs. 65.2%, respectively) of both study arm (gemcitabine + cisplatin + veliparib) and control arm (gemcitabine + cisplatin) from a phase II open-label, randomized multicenter trial. Despite the unprece...
What initial systemic approach will you recommend for metastatic pMMR HER2-positive esophageal/GEJ/gastric adenocarcinoma with PDL1 of 0?
FOLFOX-trastuzumab-pembrolizumab is consistent with the 2023 Immunotherapy and Targeted Therapy for Advanced Gastroesophageal Cancer: ASCO Guideline (Shah et al., PMID 36603169). In KEYNOTE-811, a response benefit was shown by adding pembrolizumab to trastuzumab plus chemotherapy. In this trial, 13%...