Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the best approach to organ confined squamous cell cancer of the prostate?
This is a very unusual situation in the US and other developed countries. Most of the patients with this histology tend to have other chronic illnesses to the pelvis prompting the development of this chronic inflammatory driven disease. As such, they can represent difficult situations to treat. From...
For a young patient with small cell bladder cancer, what would you recommend following cisplatin + etoposide, if scans show no evidence of distant disease and repeat TURBT shows no malignancy?
We would proceed with locoregional definitive therapy with either radical cystectomy & PLND or (chemo)radiation. Would not rely on TURBT alone. Limited datasets from MDACC slightly favor radical cystectomy but there is no high level evidence comparing surgical vs (chemo)radiation consolidation strat...
What is your experience with comparative toxicities of the available 1L combination regimens in metastatic ccRCC?
Toxicity profile is very important in choosing a regimen, noting that no direct comparisons exist. Ipi/nivo is characterized by more initial, inflammatory toxicity, but relatively well tolerated nivo monotherapy maintenance and the ability to be off all therapy for a subset of patients. IO/TKI combo...
When do you offer a boost for patients receiving 5 fraction whole breast radiation as per UK FAST Forward?
Any data (convincingly) supporting the use of boost comes from the non-hypofx era. In the START A/B trials (which included many "traditionally boostable" patients), boost/no-boost outcomes were analyzed (left up to each center's/doc's preference), and boost had an almost perfectly zero effect on out...
For young patients with smoldering multiple myeloma who wish to be treated with lenalidomide, how do you go about harvesting their cells for an autologous transplant?
I have serious reservations with treating smoldering myeloma with lenalidomide and in general, discourage it. That is likely a discussion for another day, but my thoughts on this have been summarized here. In general, we are able to secure permission for 'collect and store', and so I would prefer t...
How do you dose concurrent chemotherapy with once daily radiation for bladder preservation in urothelial carcinoma?
Two contemporary trials which used daily radiotherapy and concurrent chemotherapy are BC2001 and RTOG 0712 with concurrent chemotherapy schedules as below. Other regimens such as platinum alone have been reported on as well.BC2001: 5FU: 500mg/m²/d d1-5 & d16-20 MMC: 12mg/m² d1 Rationale: The study...
How do you treat metastatic HER2 positive breast cancer in a patient with hepatic visceral crisis?
I recently had a patient who presented with de novo HER2+ metastatic breast cancer and acute liver failure secondary to extensive liver metastasis. Her AST/ALT were > 5 times ULN and T. Bili was > 6. Docetaxel is not an option in this setting therefore, I opted to treat her with gemcitabine plus car...
In a patient with progressive thrombocytosis but negative MPN mutations on peripheral blood, what are your diagnostic and treatment recommendations?
I agree with Dr. @Dr. First Last. A bone marrow biopsy is helpful in a case like the one described as morphology can be informative in distinguishing triple negative ET vs pre-MF vs MF and also CML. I agree with NGS panel to see if there are clonal markers identified, testing for BCR-ABL is critical...
Would you move to a venetoclax-based regimen for a patient with pentarefractory MM and t(11;14) translocation, previously treated with bortezomib and carfilzomib?
To clarify what is meant by pentarefractory, we are referring to a situation where a patient's myeloma has proven resistant to two proteasome inhibitors (bortezomib, carfilzomib), two IMiDs (lenalidomide/pomalidomide), and an anti-CD38 monoclonal antibody (daratumumab/isatuximab). There are not many...
In a patient with HR B ALL and severe pancreatitis due to peg-asparaginase, how do you assess the impact of peg discontinuation on risk of relapse?
We know from Gupta et al., PMID 32275469 that omission of asparaginase courses from a mBFM chemotherapy backbone has an adverse prognostic impact among NCI HR patients. In fact, complete discontinuation of asparaginase was associated with a 50% increased risk of an event among HR patients. Thus, whe...