Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your preferred first line regimen for myeloma with severe renal impairment, either on or off dialysis?
In general, for patients with renal insufficiency related to their myeloma, time is nephrons. So the earlier you can correct the hypercalcemia, lower circulating uric acid, stop ongoing bad behaviors (NSAID overuse, etc), and treat the myeloma, the better. If the patient is admitted, I will give pa...
Among non-HRRm castrate resistant prostate cancer patients, are there features predictive of response to PROPEL regimen of abiraterone/olaparib?
There is a theory that abiraterone can lead to changes in the tumor that could make it susceptible to PARP inhibitors. I understand that the clinical trial suggests that this may be the case, but I think we need more information as to whether or not this is actually happening.
In a patient with extensive stage small cell lung cancer and a neurologic paraneoplastic syndrome do you feel comfortable using an ICI along with the chemotherapy?
I have not used immune checkpoint inhibitors (ICI's) in patients with SCLC that have neurological paraneoplastic syndromes. These syndromes can be quite debilitating and given the risk of exacerbation of the symptoms by ICI use, I have not used them in this setting. One has to remember that the use ...
What criteria does your institution use to indicate patient is ready for PEG tube removal?
The short answer is we typically advise patients that if they can maintain an oral diet (using the tube for flushes only) for 2 weeks and demonstrate no weight loss they are typically ready for tube removal. Our patients though are followed through the course of their treatment by a dietician, and t...
Are there any differences in your approach to therapy for secondary versus primary myelofibrosis?
Good question. I will risk stratify patients with secondary MF using the MYSEC-PM score and primary MF patients using DIPSS+ or MIPSS. Anecdotally, patients with secondary MF tend to have more indolent MF and there is definitely a grey zone period when you know they are transforming but still doing ...
Is IL-6 inhibition an option in patients who are going to be rechallenged with checkpoint inhibitors after previously developing ICI-mediated temporal arteritis?
There are reports of using IL-6R inhibition in combination with checkpoint inhibitor therapy in other scenarios (e.g. inflammatory arthritis, cytokine release syndrome). So this would be a reasonable consideration if the oncologist feels strongly that further ICI therapy is beneficial.
Can you continue checkpoint inhibitor therapy in the setting of severe cutaneous irAE while concurrently treating the cutaneous reaction?
Cutaneous reactions from immune checkpoint inhibitors (ICPi) generally fit into 3 categories: rash/inflammatory dermatitis, bullous dermatoses, and severe cutaneous adverse reaction (SCAR). For grade 1-2 rash/inflammatory dermatitis, if symptoms can be managed with topical therapy or non-steroidal o...
Would the recent use of high dose glucocorticoids impact your selection of first-line therapy for patients with intermediate-poor risk metastatic RCC?
Definitely a common clinical scenario, unfortunately. Such patients often have poor risk highly symptomatic disease. In such symptomatic patients, we tend to prefer a VEGF/TKI-based regimen as first line therapy considering the relatively lower rate of primary progressive disease, higher objective r...
How do you approach treatment for a patient with a biochemical relapse while on maintenance lenalidomide after autologous stem cell transplant for multiple myeloma?
Biochemical relapse (i.e. increase in M-spike or light chains meeting criteria for progression on two occasions without clinical progression) is an indication for starting treatment in my opinion. I have seen some recommend increasing the dose of lenalidomide to 25 mg in the hopes this will bring di...
Would you ever switch capmatinib to tepotinib or vice versa for patients with NSCLC with MET ex 14 skipping mutation who are responding to treatment but with ongoing edema despite dose reductions?
The MET TKIs universally cause edema that progressively develops and persists with these drugs. Unfortunately, switching from capmatinib to tepotinib or vice versa will not improve the peripheral edema. Symptomatic treatment and dose interruption or reduction are the best management strategies.