Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Do you ever withhold PCI for elderly patients with limited stage SCLC?
In my opinion, the findings by Takahashi et al, Lancet 2017 regarding the lack of survival benefit of PCI as compared to MRI observation in patients with extensive SCLC has re-opened the question of the survival benefit of PCI in limited SCLC in the modern imaging era. Hopefully, a phase III study o...
When TPN is a barrier to enrollment in hospice for an eligible cancer patient with an irreversible malignant bowel obstruction, how do you approach the conversation about discontinuation of TPN?
This is such a tough question with no great answer. With any difficult conversation like this, I usually take this approach: 1) Understand what the patient's goals are. ("What's most important to you?") 2) Usually they say living as long as possible/as well as possible 3) Acknowledge that goal as r...
How would you treat anal cancer in a patient with non-dialysis dependent severe chronic kidney disease that precludes the use of cisplatin?
How would you approach definitive nonsurgical management for biopsy-proven, localized small cell carcinoma of the prostate?
Rare disease and one patient we treated with cis plus etoposide with RT added with second cycle. Because of concern about unsampled mixed high grade histology we planned to treat to 70 Gy. No PCI as isolated brain relapse for pelvic small cell is not same as for small cell of lung
How would you treat a patient with widely metastatic clear cell RCC who has undergone craniotomy/resection of a single brain metastasis?
Initial therapy in the front line setting for a person with widel metastatic disease would include either sunitinib or pazopanib. I would not use IL2 in this setting because of the recent brain surgery. Clinical trials should also be considered,
How do you manage a patient who has developed a symptomatic pleural effusion while on dasatinib?
A variety of approaches to dasatinib-induced pleural effusion are possible. It is common to rechallenge the patient with dasatinib once the effusion resolves. You can rechallenge with the standard dose if the grade of the initial effusion was grade 1 or 2 (by CTAE grading) or at 50 mg if the effusio...
How would you treat a patient with metastatic NSCLC >50% PDL-1 positive AND an EGFR or ALK gene mutation/rearrangement in the first-line setting?
There have been multiple reports showing a positive association between EGFR activation (through mutational activation and/or signaling) and PDL1 expression (e.g. J Thorac Oncol 2015 Jun;10(6):910-23). Similarly, there are some reports of a similar association with ALK translocation (e.g. Clin Cance...
How do you logistically give sandwich chemotherapy and whole pelvis radiation treatment in advanced endometrial cancer?
We prefer concurrent or sequential. But in the past when we have done sandwich, we have used RT after 3 cycles of chemotherapy based on most of the published data.
Would you treat a patient with HIV or hepatitis C with an anti-PD-1 agent?
Yes, anti-PD-1 agents can be used in patients with HIV or hepatitis C if the viral infection is well controlled. In preclinical studies, PD-1 blockade has been shown to be a promising immunotherapy for HIV and Hepatitis C. This is based on the observation that progressive loss of effector function i...
Would you recommend prophylactic mastectomy if a patient's estimated lifetime risk of breast cancer using the Gail or Clause models approaches that of a person with a germline BRCA1 mutation (eg >65-85%), in the absence of high risk mutations?
It is premature to recommend prophylactic mastectomies to this patient. The recommendation would be for recommendation of expanding genetic testing in the affected mother or sister utlizing a larger panel of breast cancer susceptibility genes, if they are available for testing and amenable to do so....