Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would differentiating between embryonal vs alveolar rhabdomyosarcoma of the nasal cavity change your neoadjuvant chemotherapy regimen or make you consider neoadjuvant radiation in a locally advanced pleomorphic RMS?
The historic Embryonal vs. Alveolar differentiation is being replaced by a (PAX-FOXO) fusion positive vs. negative classification given the prognostic significance. In either case, the chemotherapy regimen is not likely to change in an adult patient. Pleomorphic RMS on the other hand, more common in...
Would concurrent endocrine therapy and PARPi maintenance be safe and appropriate after surgical treatment/adjuvant chemotherapy for a patient with BRCA1 mutated synchronous early stage HR+ breast CA and Stage IIA Fallopian tube carcinoma?
This does seem like a reasonable approach, based on my knowledge of eligibility criteria and tolerance in the OlympiA trial, which was a randomized trial of olaparib vs placebo in BRCA mutation carriers. In the OlympiA trial, patients with BRCA 1/2 mutation and hormone receptor positive breast cance...
When do you check for EPOR gene mutations in your workup for erythrocytosis, and if found, how do you manage it?
Only consider it in instances where there is a life-long (or at least long-term) erythrocytosis and there is no evidence of a secondary erythrocytosis. There is no role for ASA or HU in these instances. I generally do not use phlebotomy either, unless the hematocrit is extreme and the patient is sym...
For an otherwise healthy post-menopausal woman with early stage HR+ BC and persistent AI intolerance, is there an age cutoff above which you would consider avoiding adjuvant tamoxifen therapy?
There is no age cut-off based on chronological age. However, physiologic age and comorbid conditions are what I would use. For example, a 72 yo with diabetes, hypertension, and coronary artery disease is likely to die of her underlying conditions and not early stage breast cancer (Ording et al., PMI...
What is the best approach to organ confined squamous cell cancer of the prostate?
This is a very unusual situation in the US and other developed countries. Most of the patients with this histology tend to have other chronic illnesses to the pelvis prompting the development of this chronic inflammatory driven disease. As such, they can represent difficult situations to treat. From...
For a young patient with small cell bladder cancer, what would you recommend following cisplatin + etoposide, if scans show no evidence of distant disease and repeat TURBT shows no malignancy?
We would proceed with locoregional definitive therapy with either radical cystectomy & PLND or (chemo)radiation. Would not rely on TURBT alone. Limited datasets from MDACC slightly favor radical cystectomy but there is no high level evidence comparing surgical vs (chemo)radiation consolidation strat...
What is your experience with comparative toxicities of the available 1L combination regimens in metastatic ccRCC?
Toxicity profile is very important in choosing a regimen, noting that no direct comparisons exist. Ipi/nivo is characterized by more initial, inflammatory toxicity, but relatively well tolerated nivo monotherapy maintenance and the ability to be off all therapy for a subset of patients. IO/TKI combo...
For young patients with smoldering multiple myeloma who wish to be treated with lenalidomide, how do you go about harvesting their cells for an autologous transplant?
I have serious reservations with treating smoldering myeloma with lenalidomide and in general, discourage it. That is likely a discussion for another day, but my thoughts on this have been summarized here. In general, we are able to secure permission for 'collect and store', and so I would prefer t...
How do you dose concurrent chemotherapy with once daily radiation for bladder preservation in urothelial carcinoma?
Two contemporary trials which used daily radiotherapy and concurrent chemotherapy are BC2001 and RTOG 0712 with concurrent chemotherapy schedules as below. Other regimens such as platinum alone have been reported on as well.BC2001: 5FU: 500mg/m²/d d1-5 & d16-20 MMC: 12mg/m² d1 Rationale: The study...
In a patient with progressive thrombocytosis but negative MPN mutations on peripheral blood, what are your diagnostic and treatment recommendations?
I agree with Dr. @Dr. First Last. A bone marrow biopsy is helpful in a case like the one described as morphology can be informative in distinguishing triple negative ET vs pre-MF vs MF and also CML. I agree with NGS panel to see if there are clonal markers identified, testing for BCR-ABL is critical...