Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage patients with oligometastatic CRC who have completed 6 months of chemotherapy with favorable response followed by partial hepatectomy, while awaiting resection of the primary tumor?
Approximately 14-25% of colorectal cancer present with synchronous colorectal liver metastatic disease (CRLM). There are three treatment strategies: classic, combined, and reverse. The classic approach is to get the primary tumor resection first then systemic chemotherapy followed by liver metastase...
How would you manage a CLL patient with Richters transformation that is resistant to R-CHOP with transfusion dependent cytopenias and a marrow demonstrating significant involvement by DLBCL and CLL?
Very hard situation. Probably this patient has received BTKi and venetoclax based therapies already. These cases are difficult to treat. There are no standard therapies. Ideally, I try to take them to CAR-T therapy. The challenge is how to collect due to significant cytopenias due to extensive marr...
Would you give IV iron for low TSAT in patients with MDS anemia who are transfusion independent but on an ESA?
Yes. The literature is replete with evidence that iron restricted erythropoiesis mitigates optimal responses to ESAs. It is overwhelmingly likely that an individual receiving erythropoietin or darbepoetin will enjoy longer intervals and dose reduction if the IRE is corrected. I administer a gram of ...
What are your triggers for BM biopsy in polycythemia vera?
We may do a BM biopsy at diagnosis for pediatric patients, but do not generally do them as part of our diagnostic work-up, especially if JAK2 mutant. However, if there is evidence for myelofibrosis (falling counts) or leukemic transformation, we would do a biopsy.
How do you approach treatment for ovarian carcinosarcoma that has progressed during adjuvant carboplatin, paclitaxel, and bevacizumab following optimal tumor reductive surgery?
Recurrent ovarian carcinosarcoma (OCS) is a difficult clinical scenario with few evidence-based options. Clearly, a need exists for novel therapies, and a frank discussion on treatment goals and expectations is warranted. Ovarian carcinosarcoma (OCS) is a rare histologic subtype of ovarian cancer ac...
In terms of contraception, what do you recommend for patients with a history of hormone receptor-negative compared to hormone receptor-positive breast cancer?
Avoid oral contraceptives. Prefer barrier contraception and IUD.
Do you perform a periodic PET CT to screen for extramedullary disease in patients with MM who are in remission?
This is an excellent question with guidelines and inferences from clinical trials, but admittedly, no randomized data showing that surveillance PETs improve outcomes versus as-needed PETs. To start, here's what NCCN guidelines recommend for patients in surveillance/on maintenance therapy alone: "Who...
Where does Elotuzumab-based combination therapy, specifically EPd, fit in your treatment paradigm for relapsed MM?
The ELOQUENT-2 study evaluated Elotuzumab+Len/Dex vs Len/Dex alone showing improved PFS that was statistically significant and 4-year OS proportion of 50% vs 43% (HR 0.78, 95% CI 0.63-0.96). This required patients essentially be lenalidomide naive in 90% of the study population - something that is v...
Do you offer durvalumab in combination with gemcitabine and cisplatin in patients with metastatic ampullary adenocarcinoma, given the fact that ABC-02 trial included patients with ampullary adenocarcinoma while TOPAZ trial excluded those patients?
Unfortunately we don't have robust contemporary data for ampullary adenocarcinoma. In general I would not apply the TOPAZ-1 study findings to this population.
Do you hold ADT prior to biopsy of possible prostate cancer metastatic disease?
ADT can affect the ability to assign a Gleason score, but I am assuming this is not an issue here. We biopsy new sites of metastatic disease in people on ADT all the time to confirm progression and to get tissue to identify potentially actionable targets. The only time I would deliberately hold ADT ...