Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach heparin management in patients who have suprathetherapeutic Xa levels on minimal heparin?
Assuming heparin is administered using standard weight-based dosing, that the infusion rate is being accurately monitored, and that the assay was done properly, very high anti-Xa levels that persist despite lowering the heparin dose would be most unusual. In that setting, I would suspect that either...
What is your experience with using Frailty Index or other geriatric screening in making decisions for elderly patients with multiple myeloma?
The IMWG frailty score is the most comprehensive score developed to date. While predictive, trials testing its value prospectively are ongoing. Linking age, comorbidities (Charlson), and functional scales (ADL & IADL) makes great logical sense. I don't use it. The UKMRA Myeloma XIV FiTNEss [Frailty-...
Does potential longterm risk for leukemia influence your decision for using hydroxyurea in young patients with myeloproliferative neoplasms?
Thanks for the great question. I think there is a range of passionate options about the matter, which is sure to stir up debate. One can infer by the number of opinions on the topic, the data is limited (where data lacks, opinions abound). So here is my take: It does not influence my decision making...
What maintenance therapy, if any, do you offer patients with metastatic HER2+ esophageal or gastric cancer?
When is postmastectomy radiation therapy indicated for a de-novo occurrence of cancer in the chest wall after mastectomy without prior malignancy, such as in a patient who had prophylactic mastectomy?
This is such a rare occurrence and I may have done this a few times. I have usually limited to CW only if SNLN is done as part of surgery and is negative. That being said, feel local excision alone with adjuvant systemic treatment as indicated may be an option.
How do you manage real-time release of pathology and radiology results to oncology patients following enaction of the CURES act?
Even prior to the Cures Act, I worked in a place where lab and imaging results were immediately available to patients through their smartphone app. A few memorable encounters: Patient 1 - told me his favorable PSA result when I walked in the room and basically told me the plan going forward, (which ...
What adjuvant treatment would you recommend for a patient with node positive TNBC who did not receive neoadjuvant chemotherapy?
So much of our work has focused on making sure we deliver neoadjuvant therapy to patients with TNBC. However, sometimes patients don't follow rules. They may have a very small primary that is T1a or b and no obvious nodes and then surprise nodal disease, or the patient refuses chemotherapy initially...
Would you offer adjuvant chemotherapy to a woman in her 40's s/p TAHBSO with T2N1 ER+/PR+ breast cancer with oncotype score 21-25?
Based on RxPONDER trial, post-menopausal women with operable, hormone receptor positive, HER2 negative breast cancer with metastatic disease to 1-3 axillary nodes derived no benefit from chemotherapy if Oncotype dx recurrence score was 25 or less. Analysis by age did not affect this. I would, theref...
What additional benefit does radiation offer for a patient <65 years old with T1aN0 ER+ invasive carcinoma (tubular histology) of the breast?
Most of these have low genomic scores and are part of the DEBRA trial and up until that, based on available evidence, would favor adjuvant RT (APBI preferred).
How do you manage new brain mets in a patient with a history of RT necrosis after prior SRS?
The short answer is “yes”. For brain mets over 2 cm in maximum diameter, we and others have found that 3-5 fraction stereotactic radiation therapy has produced equivalent or better local control and lower incidence of radionecrosis than single fraction stereotactic radiosurgery. It would be good if ...