Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage a patient with a history of high-risk leukemia who has increasing loss of donor chimerism in the post-transplant setting in the absence of disease relapse?
Decline in donor chimerism is not very common in pediatric patients who underwent myeloablative conditioning regimen for hematologic malignancy, and if chimerism is initially 100% and subsequently falls, it usually represents a relapse of underlying leukemia, or a new malignancy. I always obtain lin...
Would you offer adjuvant chemotherapy to a patient with high grade pT1 bladder cancer with concurrent pT2 prostatic urethral stroma involvement?
I would adopt the data from the CheckMate 274 trial. If the patient is post-neoadjuvant cisplatin-based chemotherapy, I would consider adjuvant nivolumab, especially if the tumor PD-L1 is high and/or post-op ctDNA is positive for minimal residual disease. If the patient has not received neoadjuvant ...
Do you obtain biopsies to confirm positive DOTATATE PET scans during surveillance or treatment?
The answer to this question all depends on the clinical scenario. Modern-day SSTR PET imaging (Ga68 DOTATATE, Ga68 DOTATOC, Cu64 DOTATATE) has both sensitivity and specificity over 90 percent for NETs (van de Berg et al., PMID 29025892). Thus, if you have uptake in, for example, the liver, a mesente...
How would you treat gray zone lymphoma which initially achieved a CR after 2 cycles of DA-R-EPOCH, but end-of-treatment PET demonstrates progression with new sites of biopsy-proven disease?
While admittedly the (non randomized) data comes from HL, would consider pembro-GDP vs BV/nivo with the plan to go to auto.
How does the presence of concurrent infections or wound issues affect your choice and timing of induction in patients with AML or MDS with excess blasts?
Many patients are diagnosed with AML or MDS with excess blasts after presenting with acute infections. In these circumstances, early recognition and initiation of broad spectrum antibiotics to prevent sepsis is essential. We typically delay induction chemotherapy until the infection is under control...
Would you offer anti-HER2 therapy to a patient found to have heterogenous HER2+ residual disease after original treatment for TNBC using the KEYNOTE-522 regimen?
This is complicated and there isn't a data driven right/wrong answer for this type of situation that I am aware of. Neoadjuvant treatment can cause shifts in biomarker results in residual tumor tissue compared to the pre-treatment specimen. KY-522 didn't do re-testing of residual tumor. I am not rou...
How does your approach to low-risk gestational trophoblastic neoplasia differ for patients whose hCG levels plateau following initial single agent systemic therapy vs those who have a good initial response and then plateau?
For patients with low risk GTN whose hCG values plateau over a two-week interval, concerns arise about chemoresistance. Unfortunately, there is no consensus or clear guideline in terms of determining chemoresistance and when to switch therapy. I don't approach the two clinical scenarios presented he...
What is your surveillance strategy in patients with brain metastases who are getting systemic therapy?
Generally, I’d consider a repeat MRI every 2-3 months, earlier if warranted. Assuming no evidence of disease progression for 1 or 2 years, I’d consider every 3-6 months.
Do you advocate for dose dense AC instead of every 3 week dosing in neoadjuvant TNBC as done in KEYNOTE 522?
When giving neoadjuvant therapy for TNBC as given in the KEYNOTE-522 study, I prefer to administer dose dense AC (with growth factor support) + pembrolizumab (after completing weekly paclitaxel and carboplatin + pembrolizumab). While there has been no comparison of dose dense vs. q3week AC with this...
How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?
This is a very important question, and I think rheumatologists will encounter cases like this more frequently as immune checkpoint inhibitors (ICIs) are being increasingly used. Roughly, 50% of patients with co-existing autoimmune disorders and malignancies have flare-ups of their autoimmune disorde...