Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach the management of newly diagnosed metastatic colon cancer in a patient who experienced infusional 5FU-related cardiotoxicity with initial chemotherapy?
I have a patient who developed documented coronary spasm with EKG changes and troponin elevation on 5 FU infusion, given as part of FOLFOX cycle 1, 3 weeks ago. She is now on the FLOX regimen with Isosorbide mononitrate and amlodipine prescribed by cardiology with specific dosing and timing recommen...
How would you treat a BRAF mutated and KRAS WT metastatic colon cancer who has progressed after FOLFOX and now Irinotecan + cetuximab + vemurafenib?
We have encountered this in our clinic. We opted for clinical trial referral. The BEACON trial showed an impressive ORR of 48% with encoragenib, binimetinib and cetuximab, however, patients with prior exposure to any RAF or MEK inhibitor, cetuximab, panitumumab, or other EGFR inhibitor were excluded...
How do you manage significant fatigue caused by androgen deprivation therapy in prostate cancer patients?
This is a great question and one that I think comes up regularly in the clinic. The fatigue often is due to the hypogonadal state, lack of muscle mass and subsequent loss of muscle power that may reduce stamina. I generally recommend a regular activity or exercise program. As in many other patient p...
For metastatic NSCLC patients with mixed response to pembrolizumab, would you radiate focal progressing lesions and continue pembrolizumab, add in chemotherapy to pembrolizumab, or discontinue pembrolizumab and move to second line?
These are all reasonable approaches. The better and longer the prior response to pembrolizumab and the more limited the # of progressing sites, the more likely I would be to consider radiating those sites and continuing pembrolizumab alone. I have not yet added chemotherapy to pembrolizumab, but wou...
How would you approach first-line treatment in a young patient with VHL with intermediate/poor risk metastatic clear cell RCC?
Is there currently a role for adding venetoclax to a hypomethylating agent (HMA) after failure of single-agent HMA therapy in MDS?
For patients with MDS who have failed single-agent HMAs, there is an intriguing small retrospective series suggesting that adding on Venetoclax at the time of HMA failure can lead to responses (Ball et al., PMID 32589727). Because of the retrospective nature of this publication and the small numbers...
How do you manage venous thromboembolic events or bleeding events in RCC or HCC patients on anti-angiogenic TKIs?
I generally would not discontinue for a bleeding event for an RCC pts on anti-VEGF therapy. I may hold drug while managing the event if I can control the source of bleeding, but given most options include such an approach would restart cautiously. Similarly for venous thrombotic events I would manag...
How would you approach adjuvant chemotherapy for high grade pleomorphic/dedifferentiated liposarcoma?
These are not impressive results for a retrospective study where I am sure fitter patients are probably selected for therapy. these are very toxic drugs. Can you break down the numbers of pleomorphic in this abstract ( unpublished) to see if we can get a better idea What level of evidence should we ...
Would you perform an oncotype DX in a patient with a 0.5cm ER positive breast cancer with one lymph node positive for macrometastatic disease?
We published data from SEER in May of last year (Massarweh, JCO May 2018) looking at BCSS and OS in 55 thousand women with 0-3 lymph node involvement at 5 years. In patients with low and intermediate RS (up to 30) there is very little difference between node negative and node positive patients in te...
How would you manage DCIS diagnosed in the first trimester of pregnancy?
During the first trimester of pregnancy organogenesis takes place and thus the risk for teratogenic effects of systemic therapies are the greatest. Given that DCIS is a non-invasive form of breast cancer associated with excellent prognosis, my preference would be to wait until at least the second tr...