Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you restart endocrine therapy for a patient with new contralateral LCIS diagnosed 2 years following completion of AI therapy for stage 1A HR+ IDC?
The primary prevention trials (NSABP-1, STAR, etc) largely excluded women with a prior history of cancer and certainly did not include those who'd had 5 previous yrs of endocrine therapy. While I think you could discuss an additional 5 yrs of endocrine therapy, an additional 5 yrs of AI (e.g. 5-10 t...
In what clinical scenarios do you utilize venetoclax-based therapy in relapsed/refractory multiple myeloma?
I would caution that there is no strong data that the combination of Venetoclax with a proteasome inhibitor or a CD38 antibody makes sense; in fact, the addition is more likely than not to cause harm. Adding on to Venetoclax in patients that are naive to proteasome inhibitor or CD38 Ab naive is jus...
In what scenario would you add systemic therapy with adjuvant radiation therapy in resected, locally-advanced, cutaneous squamous cell carcinoma?
This is an active area in clinical trials, here is a recently published reviewNewman et al., PMID 34096664 More to come in a future post, I will see what trials are currently available in the Chicago area!
Why do we use dexamethasone for CNS edema and prednisone for pneumonitis?
Dexamethasone has better CNS penetration compared to prednisone and thus its established use for managing vasogenic edema. However, it has the most suppressive effect on ACTH, causes relatively more steroid myopathy and has less mineralocorticoid effect compared to prednisone hence, the general use ...
For locally advanced NSCLC with additional synchronous NSCLC primaries in the same lung or lobe, what is your approach to definitive therapy?
This is a situation that comes up surprisingly frequently and can be challenging to navigate. This assumes that one is certain which of the two lung lesions is the primary (i.e. based on discordant pathology or genomic profiling results of the nodal metastasis and/or first primary compared to the se...
What is your preferred first line treatment for metastatic follicular dendritic cell sarcoma?
This entity saddles the lymphoma-sarcoma group of tumors. Typically treated with SOC Rx for lymphoma first before considering sarcoma-specific regimens.
How would you approach a patient with imaging and labs suggestive of potentially resectable cholangiocarcinoma when several core biopsies reveal bridging fibrosis with no malignant cells?
I believe the first step would be presenting the patient's imaging and case at a multidisciplinary tumor board for input, especially from GI and surgical oncology, ideally at a higher volume center. You don't specify the route of prior biopsies but I am assuming they are percutaneous. Perhaps yield ...
How do you manage neuropathic chemotherapy agents in patients with underlying multiple sclerosis?
I would make sure that if they do have B and T cell immunosuppressive effects (I would check their FDA access data records, phase 3 clinical trials, other drug sites that detail their MOA) and I am convinced that my MS drugs (if the patient is on any) are not needed, I would discontinue such therapy...
Should a pregnant woman who is heterozygous for factor V Leiden who has never had a thrombotic event receive prophylactic anticoagulation?
This is a common situation and lacks evidence based recommendations. Recent ASH guidelines (Bates et al., PMID 30482767) suggest against routine antepartum prophylaxis in this situation. However, it is important to have a balanced discussion with the patient. In my experience, most would choose prop...
How would you approach therapy for a patient with non-seminomatous germ cell tumor, cT3N3Mx and symptomatic lower extremity thrombus extending to the IVC when it is unclear if bland or tumor thrombus?
This is not a common setting, but it is well described and high volume centers have fairly uniform approaches to patients presenting with caval thrombus. With the pre-orch HCG of 850, he is likely IGCCC good risk unless he is found to have brain or hepatic mets. He is likely non seminoma with a larg...