Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you start immunotherapy in a patient with metastatic melanoma who is on steroids (e.g. dexamethasone for cerebral edema)?
In general immunotherapy should not be started if patients require predisone or the equivalent more than 10 mg a day.
Do you prefer rhTSH for TSH stimulation instead of thyroid hormone withdrawal when treating patients with radioactive iodine for papillary thyroid carcinoma?
There are no long-term level 1 evidences to guide the decision between rhTSH stimulation and TSH withdrawal in preparation of radio-iodine ablation. Two largest randomized studies (Strategies of radioiodine ablation in patients with low-risk thyroid cancer.N Engl J Med. 2012 May; 366(18):1663-73. Ab...
In the absence of an available clinical trial, would you favor regorafenib immediately post-sorafenib or nivolumab in patients with HCC?
At this point in time, given the continued encouraging data regarding the efficacy of immune checkpoint blockade in HCC coupled with the substantially lower toxicity when compared to regorafenib, I would choose off-label nivolumab in this particular scenario.
When do you consider for first-line atezolizumab for metastatic bladder cancer?
I see these patients in 2 groups, "cisplatin-ineligible" or "chemotherapy-ineligible”. In the “cisplatin- ineligible” group one may consider a carboplatin-based regimen (carboplatin plus gemcitabine or carboplatin plus taxol) or atezolizumab. In “chemotherapy-ineligible”, I consider both performanc...
Do you intentionally modify your breast cancer treatment plans for those on chronic immunosuppression to avoid secondary cancers?
This will usually depend on their clinical scenario. In case where I would recommend RNI, I will still recommend RNI and counsel on risks of second canceers. In patients with early stage lower risk or disease, one can consider partial breast irradiation if appropriate though I do counsel patients th...
What is the upper limits of anthracycline dose you are willing to give in a treatment-refractory metastatic breast cancer patient if the patient is responding to salvage weekly adriamycin after progression on multiple prior regimens?
I would not normally exceed 350-400 mg/m2. However, this is a tough situation in that the patient is treatment-refractory without many other great options and responding. According to the package insert, "the probability of developing impaired myocardial function based on a combined index of signs, ...
Do you resume immunotherapy (such as nivolumab) for metastatic melanoma after therapy-induced grade 4 hyperglycemia that has resolved?
The answer is probably yes depending on the circumstances. If on a trial then no. If SOC then could consider it and since the patient probably has the equivalent of type 1 diabetes requiring insulin supplementation then unlikely to hurt them more. If the pancreas recovered then it would be a risk be...
For ALK+ patients rendered NED from oligometastatic NSCLC after resection of both lung primary and isolated CNS lesion, do you consider offering treatment with an ALK inhibitor after adjuvant chemotherapy, or do you place into surveillance?
A large proportion of patients with oligometastatic disease managed with curative intent generally relapse, either intracranially and/or extracranially. TKI therapy maybe expected to prolong disease-free/progression-free survival based on our experience with EGFR TKIs. However, given the expected du...
How would you approach a chronic phase CML patient who is responding to second generation TKI but not yet in molecular remission and is now pregnant?
If the patient is now pregnant, I would stop the TKI immediately, and initiate therapy with interferon. If that is not tolerable, I'd recommend hydroxyurea, although it will likely not control relapse into overt chronic phase.
How do you manage a patient with a history of non-seminomatous germ cell tumor who has a rising AFP after primary chemotherapy without any imaging evidence of recurrence?
It would depend on the timing of the rise of AFP after chemotherapy, how elevated it is, whether they were good or poor risk patients at the time of chemotherapy, whether they had liver disease and whether the AFP was definitively elevated prior to chemo In most cases, we sort of ignore AFP < 25 or ...