Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Are there best practices or data regarding the use of open notes among oncology patients?
The 21st Century Cures Act regulation (effective April 2021) required that clinical notes such as consult and office notes be shared with patients, e.g. “open notes.” In general, surveys of patients with cancer and their clinicians suggest that open notes are viewed favorably (Salmi et al., PMID 330...
How would you manage tucatinib-associated grade 2 indirect hyperbilirubinemia in a patient with metastatic HER2-positive breast cancer involving the CNS receiving trastuzumab + capecitabine + tucatinib?
Could she have a UGT1A1 mutation? I have been doing some NGS for hereditary hemolytic anemias and have found asymptomatic Gilbert’s patients with UGT1A1. Tucatinib also has a decrease in UGT1A1 listed in pharmacokinetics so it could lead to a totally harmless indirect hyperbilirubinemia. Checking mi...
Do you treat stage 1 non-seminoma differently if there is a component of embryonal carcinoma?
No.
How would you approach a patient with resected renal cell carcinoma, collecting duct type with sarcomatoid and rhabdoid features?
Although sarcomatoid differentiation is more common in clear cell RCCs, it is also well described in other RCC subtypes, including collecting cell carcinoma. Some argue that collecting duct carcinoma is histologically and clinically closer to a urothelial carcinoma than an RCC subtype. Urothelial ca...
How would you treat prostate cancer that recurs after radical prostatectomy with invasion into bladder, rectum and musculature?
In a case with extensive disease like this, I would first restage ideally with a molecular study like PSMA to ensure no evidence of metastatic disease. In the absence of metastatic disease, I would recommend starting with ADT (+/- abiraterone or other novel anti-androgen) to downsize disease away fr...
Based on the STAMPEDE trial pooled analysis, which patients with high risk prostate cancer would you add abiraterone for 2 years?
I often use 2 years of Abi/pred (plus ADT) in patients with high-risk localized prostate cancer who have at least two of these features: Gleason grade group 4 or 5 Clinical/radiographic stage T3 or greater PSA 40 ng/mL or greater This is typically done in conjunction with primary radiotherapy.
Based on the TOPAZ-1 study, do you now routinely include durvalumab in first line treatment of advanced bile duct cancer?
YES! And it is a strong yes. TOPAZ-1 is a very elaborate study with statistically and clinically significant data outcomes. See Do et al., Journal of Clinical Oncology 2022. What is better than holding chemotherapy after 6 months and keeping patients on single agent durvalumab? And avoiding all cumu...
How would you treat a patient with prostate cancer with de novo bone and bone marrow metastases with cytopenias?
Men who present with diffuse bone marrow involvement by definition have high volume de novo disease, and among the worst prognosis of all situations. Level 1 evidence now suggests that triple therapy with ADT/docetaxel and concurrent abiraterone or darolutamide (level 1), or sequential ADT/docetaxel...
For a patient with breast cancer s/p lumpectomy found to have a heterozygous RAD50 mutation, is adjuvant radiation appropriate therapy or would you recommend completion mastectomy?
Rad50 is part of the homologous recombination repair pathway. If cancer cells have homozygous loss of Rad50, they will be exquisitely sensitive to radiation therapy, which causes lethal DNA double-strand breaks via oxygen free radicals. Theoretically, adjuvant radiation is an excellent treatment bas...
How do you manage a duodenal somatostatinoma metastatic to liver?
These should be managed like metastatic pancreatic NETs.The key is a careful evaluation, ideally in a multi-D setting, to determine if resection of the primary and mets is feasible. If not, the initial approach should be somatostatin analogs. PRRT certainly has activity in SSTR-positive disease and ...