Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant therapy would you recommend for a premenopausal woman with low ER+/PR+ (1-10%) HER2- pT1cN0 metaplastic breast cancer?
The rarity of the metaplastic subtype of breast cancer makes it difficult to provide an evidence-based answer regarding what is the "best" adjuvant treatment. About 70% of metaplastic tumors are TNBC and ER-low is a small subset of the remaining 20% with an ER+ epithelial component. In general, some...
Do the MA.20 and EORTC 22922 studies, showing no survival advantage from regional nodal irradiation in early-stage breast cancer patient following surgery, change your standard of care for these patients?
Two major landmark studies recently published simultaneously in the New England Journal of Medicine, Volume 373, 2015 (NCIC MA.20 study by Whelan et al. and the European Organization for Research and Treatment of Cancer (EORTC) 22922-10925 study by Poortmans et al.) will have a significant impact on...
How would you approach iron supplementation in a beta thalassemia trait patient with restless leg syndrome?
Thalassemia does not alter my decision. I don't use PO iron for RLS as it is enormously more toxic. A ferritin of 75 is a light-year away from iron overload, and a total dose infusion of IV iron can be administered with impunity. This patient should be treated with a gram of LMW iron dextran over on...
What is the optimal antithrombotic management, if at all, in patients with incidentally identified findings of multiple silent embolic appearing cerebral infarcts?
It is important to confirm the pattern is embolic. If unsure, input from a specialized physician (such as vascular neurology or neuro-radiology, if available) can aid in confirming the diagnosis. Various white matter findings may mimic an embolic pattern, and distinguishing between unilateral...
When do you pursue additional workup for incidental thrombocytosis in hospitalized patients?
Since most acutely ill patients will have lab evidence of acute illness, including thrombocytosis, I usually do not work it up during the hospital stay. But it should be stated in the discharge summary and followed up post-discharge.
Do you recommend vitamin C supplementation with PO iron in patients with iron deficiency?
Vitamin C supplementation is unnecessary. Taking the iron with a glass of orange juice away from food and especially coffee optimizes absorption. That being said vitamin C does no harm. See vonSiebenthal et al eClinical Works 2023 (Lancet publication), Benson et al, Lancet Haem 2025 or Auerbach et a...
Can you give Pluvicto with concurrent palliative EBRT?
Short answer: Yes, you can, and I do not modify my dose. I have no issues with this and have done it multiple times for patients who need more immediate symptom relief (pain, bleeding, etc.).Why? Because Pluvicto is a medium energy isotope with a relatively short path length of around 2 mm. Even nea...
How do you manage patients with embolic stroke of an undetermined source and a papillary fibroelastoma found on an echocardiogram?
The definitive treatment is surgical, and the only way of knowing for certain that the lesion is a fibroelastoma is to perform surgery and obtain pathology. If a patient is not a candidate for heart surgery, anticoagulation could be tried.
What features would push you towards re-operation for completion staging vs observation for a premenopausal woman with stage II borderline tumor of the ovary with capsule rupture and no other evidence of gross residual disease?
I would only reoperate if there were a survival benefit, symptomatic benefit, or change in treatment regimen. From the description, it doesn't seem like this meets any of those criteria.
Would you offer adjuvant ribociclib to a postmenopausal female with ER+ luminal A, node+ breast cancer pT1cN1a grade 2 that didn't require chemotherapy per Oncotype, but met NATALEE inclusion criteria?
I would consider it, but, unfortunately, we don't have data on the benefit (or lack thereof) of adjuvant CDK 4/6 inhibitor therapy (either ribociclib or abemaciclib) correlated with Oncotype score, but I would keep in mind that Oncotype is prognostic as well as predictive, so I am less likely to rec...