Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your treatment of choice for triple class refractory multiple myeloma?
To define triple-class refractory means the patient is refractory to FDA-approved IMiDs (up to Pomalidomide), proteasome inhibitors (bortezomib and carfilzomib), and CD38 naked antibodies (e.g. daratumumab or isatuximab). Refractory is defined as progression or within 60 days of the last dose. I ag...
What are contraindications for growth factors in patients with hematologic malignancies?
This is a challenging question where little data exist to support a good conclusion. In real world situations, patients with cytopenias and suggestion of TR-MN warrant aggressive antibodies find yourself deciding which is the "best of class" in its nature. John
How do you counsel post-menopausal patients with HR+ breast cancer who are interested in taking medroxyprogesterone?
Assuming the woman is taking this as hormone replacement therapy for menopausal symptoms, I would recommend against this. Based on several analyses of hormone replacement and breast cancer incidence (primary prevention), including the results of the Women's Health Initiative randomized trials, conju...
Do you adjust the dose of ruxolitinib in primary myelofibrosis based on hemoglobin?
This is a tough question. It generally depends on how bad the anemia is. You can expect at least a gram (or more) drop in the hemoglobin when starting ruxolitinib, so baseline hemoglobin is important. Also, assuming that the patient is symptomatic, you would want to reduce the dose as little as poss...
Is there any adjunct therapy to help with tamoxifen-induced leg cramps?
When a patient is complaining of leg cramps, it is important to make sure that the patient is not complaining of signs or symptoms of a deep vein thrombosis. If this is not a concern, one may consider checking electrolytes to make sure no other potential explanation. Otherwise, tonic water can be he...
How have you been incorporating Abemaciclib into the adjuvant management of high risk node positive HR+ breast cancer?
To date, I have used local lab results for Ki-67 and had no issues with insurance coverage. Our breast team has otherwise been attempting to utilize abemacicilib in situations that meet the monarch-E protocol (Patients with four or more positive nodes, or one to three nodes and either tumor size ≥ 5...
Is there any role for neoadjuvant chemotherapy for low grade adenosquamous metaplastic TNBC?
Metaplastic breast (about 1% of all breast cancers). These are mostly triple negative and high grade, this is described as "low grade adenosquamous (LGAS)." LGAS is a subset of metaplastic tumors, of low malignant potential (Romanucci et al., PMID 34017612). Excision alone with wide margins (1 cm or...
Would you change chemotherapy to VIP in a young patient with stage IIIB intermediate risk non-seminomatous germ cell tumor with borderline DLCO after one cycle of BEP?
The term “borderline DLCO” needs to be taken into context. The test is not completely reliable and one needs to consider the DLCO result in the clinical setting - has the patient been a heavy smoker, does he have known respiratory disease, does he have any limitation in effort tolerance, and who/whi...
For women with HR+ breast cancer and low libido due to endocrine therapy, would you consider flibanserin therapy?
I would definitively consider a sexual therapist but I do not have experience with flibanserin in this setting. We have done a review in Lancet Oncol on this topic (link below) on the pharmacological and non-pharmacological therapies available for sexual dysfunction in breast cancer patients:Franzoi...
Would you offer adjuvant immunotherapy to a patient with esophageal cancer who completed neoadjuvant chemo+RT followed by surgery a year ago?
I would not. In CheckMate 577, patients could receive nivolumab up to 4 months following surgery. In a patient who is a year out from surgery, we cannot possibly know the benefit of any adjuvant treatment. I, therefore, adhere to the clinical trial population/design.In general, I try to start treatm...