Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you treat a patient with blastoid mantle cell lymphoma with hepatic involvement causing significantly elevated bilirubin?
Tough situation. Ideally, if the cause of the liver dysfunction is the disease then based on age. The goal would be to start therapy in order to alleviate some of the disease burden to reduce the bilirubin level; if this isn't amendable, stenting or percutaneous drainage. If bilirubin can be improve...
In metastatic/recurrent clear cell carcinoma with a solitary site of metastasis to the bone when, if ever, do you consider local therapy adequate and hold systemic therapy?
If I have a patient with a treated solitary metastatic site in RCC (bone or otherwise), I generally give local therapy and historically would not give systemic therapy. A point of discussion would be use of adjuvant pembro in this setting. While bone mets were not included in KEYNOTE-564 resected M1...
What protocols or safeguards do you implement if bed bugs are found on a patient or their belongings while on the treatment table or near equipment?
Typically once a bedbug is identified, the patient is brought directly into our inpatient holding bay so that there is limited time to contaminate common areas of the department. Therapists do utilize contact precautions including knee high shoe covers. We then have our hospital facilities team trea...
Would you treat a patient with metastatic castration resistant prostate cancer and prior treatment with Ra-223 with Lu-117-PSMA-617 therapy?
Yes, assuming they are otherwise eligible with PSMA + disease, acceptable blood counts, etc. In fact, in cases with patients with bone only disease, many argue to start with Ra223 rather than Lu117 as if they progress beyond bone only disease and are treated with Lu117, they will not be able to rece...
Are there situations where you would start treatment for cardiac amyloid in a patient with amyloid seen on biopsy, but still pending mass spectrometry results?
I do not think of treating cardiac amyloid without the results of mass spec. You really need to know what type of amyloid you are dealing with.
Would you give a fit <40 year old with T3N1b low risk Stage IIIB colon adenocarcinoma 6 months of adjuvant chemo or feel comfortable limiting to 3 months of CAPOX?
For T3N1 disease, 3 months of therapy with oxaliplatin and fluoro-pyrimidine is non-inferior to 6 months. Statistically equivalent with an upper limit of 95% CI <1.12. Furthermore, on retrospective subset analysis (choice of FOLFOX or CapeOX not randomized), 3 months of CapeOX was superior to 6 mont...
How do you now approach treatment sequencing in MM in light of the DETERMINATION trial data?
There are two questions that come to mind re: DETERMINATION with respect to sequencing.1) To do early transplant or not?2) To do indefinite lenalidomide maintenance? My views on question #1 are evolving, but here is how I have unpacked it and stated elsewhere on theMednet. REASONS TO DO TRANSPLANT: ...
How do you approach continuation versus cessation of systemic therapy for patients with stage IV triple negative breast cancer with a prolonged complete response to therapy and who are tolerating therapy well?
This is a difficult question to answer. Prior studies in metastatic breast cancer that tested chemotherapy holiday showed inferior survival as compared to maintaining or attenuating systemic therapy (examples: Coates et al., PMID 3683485; Stockler et al., Breast Cancer Research and Treatment 2003; J...
Do you hold or avoid pemetrexed in patients with NSCLC and pleural effusions?
I do not. Given pemetrexed's relationship to methotrexate as an antifolate, the question has come up of whether the same precautions taken with methotrexate regarding effusions/third space fluid are necessary for pemetrexed. Thankfully, this does not appear to be the case, as several studies (here i...
In someone with an asymptomatic JAK2 V617 mutated and BCR/ABL negative MPN with a steadily rising WBC, when do you decide to start cytoreductive therapy and which agent(s) do you recommend?
First, let's abandon the phase "BCR/ABL-negative MPN". This is an oxymoron because BCR/ABL can be expressed in a JAK2 driver mutation-positive MPN. In fact, both BCR/ABL and JAK2 mutations can be expressed in normal individuals at very low levels without causing disease. Both mutations can also be p...