Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In the rare setting of enoxaparin injection-induced abdominal wall hematoma in patients requiring long-term anticoagulation, what is your timeline for restarting anticoagulation?
Abdominal wall hematomas typically occur when a vessel has inadvertently been injured during injection. Timing of resumption of anticoagulant will vary with the underlying indication for anticoagulants. For a high-risk indication, eg multiple cardiac valves in patients with history of stroke, I woul...
What is your approach to the management of hot flashes in a patient who wants to use herbal medicine?
Hot flashes are so bothersome to some postmenopausal women, especially those with breast cancer in whom we discourage the use of estrogen or potentially estrogenic, that we now have evidence from randomized trials to help guide treatment. With regard to nonprescription therapies, data thus far suppo...
What is your approach to CLL in patients with atrial fibrillation and/or on anticoagulation?
Before the availability of venetoclax, the only approved targeted oral therapy for patients with CLL was ibrutinib. Given the lack of alternative options, patients with atrial fibrillation and/or patients on anticoagulation were treated with ibrutinib. Use of anticoagulation with ibrutinib can incre...
Do you find ELEVATE-RR data and study design compelling to start preferentially using acalabrutinib over ibrutinib?
The inferiority design of the ELEVATE-RR included a 1.429 margin, but the hazard ratio between treatments was 1.0 as related to DFS and 0.82 (favoring acalabrutinib) for OS. This improved OS likely is reflective of lower cardiac events and other adverse events. To me, this is sufficiently beneficial...
Would you recommend induction chemotherapy such as TPF to a patient with locally advanced sarcomatoid carcinoma of the nasal cavity?
Sarcomatoid carcinoma of the nasal cavity is a very rare entity. There are no studies to guide optimal management. Literature support is mostly in the form of case reports. TAX-323 and TAX-324 studies did not include this histology. In general, sarcomatoid cancers are best managed by surgery (ideal...
What is your preferred maintenance strategy for high risk multiple myeloma?
Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no ...
How would you treat a patient with stage 4 NSCLC with EGFR R776H mutation?
R776H is a rare exon 20 point mutation. Preclinical models suggest that it is an activating mutation and that it is sensitive to erlotinib, afatinib, and osimertinib [Kohsaka et al., PMID 30404555]. Several case studies of patients with rare EGFR mutations have reported responses to EGFR TKIs (erlot...
For frail patients with cardiac co-morbidities and relapsed CLL with high cytogenetic risk, what are some considerations for using continuous acalabrutinib over fixed duration therapies such as venetoclax/rituximab?
This is a complicated question and I evaluate each patient individually. I worry more about patients with reduced cardiac function on BTK inhibitors than I do those with pre-existing atrial fibrillation, and if they are on anticoagulation as well, that is a further concern. If the patient has reduce...
How do you recommend differentiating between localized cutaneous melanoma of the perianal skin versus mucosal melanoma of anal canal?
Although perianal melanomas arise within squamous epithelium, I think it is better to characterize these as mucosal melanomas. I think of it as being similar to melanomas that arise within the cutaneous surface (i.e. squamous epithelium) of the vulva but are still considered to be mucosal melanomas....
In a patient with metastatic TNBC on chemoimmunotherapy for several years and a near complete response, would you consider an immunotherapy holiday?
Hard to answer this question without understanding the context of the clinical scenario. In the scenario of chemoimmunotherapy, I would drop off the chemo and maintaining single-agent immunotherapy. If the patient has transitioned to immunotherapy alone, you can only use a maximum of two years (ate...