Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you advise women who are at high risk for breast cancer and for whom annual screening breast MRIs are recommended regarding the long-term risks of gadolinium contrast?
For all breast cancer screening modalities, we need to weigh the benefits for early detection with the potential harms, such as false positive results and over diagnosis. Among young high-risk women with dense breasts, breast MRI has higher sensitivity compared to mammography for early detection of ...
How long do you continue low dose CT screening for lung cancer?
In general, I discontinue LDCT after 3 negative scans for a person undergoing lung cancer screening without symptoms. This is not true if small nodules are seen on imaging. This is based on the best data we have at the time and the possibility of risk associated with continued annual screening. The...
Does CD5 positivity by itself in DLBCL pose a high risk of CNS recurrence and necessitate CNS prophylaxis?
There are convincing data that de novo CD5+ DLBCL does confer a heightened risk of CNS relapse - in the largest series reported, this risk was 12.7% after treatment with RCHOP chemotherapy, and this despite 15% of patients having received intrathecal methotrexate as prophylaxis [https://doi.org/10.1...
How do you approach a patient with a non-castrate testosterone level and rising PSA despite receiving LHRH agonist therapy?
This is a good question. It is always good to check on the testosterone value in men on LHRH agonist therapy in order to ensure the level truly is within castrate range. I assume this patient has been on therapy for a number of months (i.e. the testosterone has had time for full suppression). If so,...
How would you treat an older patient with newly diagnosed B-ALL and significant cardiac and neurological co-morbidities?
Treating older patients with newly diagnosed B-ALL WITHOUT significant comorbidities is challenging enough! There is no accepted standard of care for the treatment of older adults with ALL, typically defined as over the age of 60. Lower intensity chemotherapy backbones with the addition of ABL kinas...
What is your preferred first-line therapy for patients with newly diagnosed intermediate- or poor-risk metastatic clear cell RCC?
For intermediate and poor risk advanced clear cell renal cell carcinoma, combination therapy is the standard of care with 4 different regimens showing an improvement in overall survival vs sunitinib: nivolumab/ipilimumab, pembrolizumab/axitinib, cabozantinib/nivolumab, and pembrolizumab/lenvatinib. ...
When can tamoxifen be safely resumed after pregnancy?
I am not aware of any formal recommendations on this and there isn't much in the literature to guide us. Certainly, there is concern for Tamoxifen use in breastfeeding mothers as it's excretion into breastmilk is unknown and it is also known to suppress lactation. There is a trial, the POSITIVE (Pau...
What is your preferred approach to therapy in transplant ineligible multiple myeloma initially treated with CyBorD owing to acute renal failure, after achieving a VGPR (+IFE alone) with continued mild-moderate renal impairment?
After completion of initial treatment, our practice is to offer patients maintenance therapy with Revlimid based on the meta-analysis of Revlimid maintenance done in patients following autologous stem cell transplant. This includes patients who have not had lenalidomide upfront. Using maintenance le...
What is your preferred first line therapy for advanced NSCLC with an EGFR activating mutation?
My current off-protocol approach is osimertinib as a single agent, though combining osimertinib with bevacizumab is being tested in an interesting clinical trial. The bev-erlo combination trials are very small with small hints of a survival benefit, but definitely improved progression-free survival....
What is your systemic therapy approach to women with isolated local recurrences of hormone-receptor positive breast cancer?
I will assume this case involves a chest wall or other local recurrence. In this case, it depends on whether the tumor is resectable. Based on the CALOR trial, wide resection, XRT (if not previously done), and anti-hormonal therapy would be the way to go. I would probably try to add a CDK4/6 inhibit...