Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach a patient with lower risk stage III colon cancer who is unable to tolerate the planned 3 months of oxaliplatin-based therapy due to neuropathy?
For a stage III patient, I would favor dropping oxaliplatin and just continuing 5FU/leucovorin for the final 3 months (total of 6 mo of treatment). As this is early to see this degree of neuropathy, consider screening for other contributing causes, such as B12 deficiency or diabetes. If this patient...
Does the presence of an ATM mutation in advanced stage ovarian cancer influence the decision to use Bev vs PARP inhibitor for maintenance?
I would not use the presence of an ATM mutation alone to inform decisions between bevacizumab vs PARPi maintenance. There are several options for maintenance in the 1L setting, and these include single agent PARPi, PARPi + bevacizumab, or bevacizumab monotherapy. Using data from the PAOLA-1 trial, i...
What induction combination(s) would be appropriate for newly diagnosed standard cytogenetic risk multiple myeloma who have a transplanted kidney?
This is a tough question! On one hand, the risk of allograft rejection with IMiDs is a real concern. On the other hand, one must consider that the evidence for this is limited to case reports/series (ex Walavalkar et al., PMID 29661456; Lum et al., PMID 28189378; Nguyen et al., Blood (2019) 134 (Sup...
How would you manage an asymptomatic elderly frail patient with newly diagnosed mantle cell lymphoma with TP53 mutation?
While p53 mutations are known to impact clinical outcome after administration of cytotoxic chemotherapy in frontline MCL (Eskelund et al., PMID 29794145, Elhassadi E et al. Presented at: 2019 European Hematology Association Congress; June 13-16, 2019; Amsterdam, The Netherlands. Abstract PF493, Ferr...
Would you continue IO monotherapy in a patient with metastatic RCC started on first line IO-TKI combination but with poor tolerance to TKI?
Yes, definitely assuming no limiting irAEs. There is clear activity to IO monotherapy in mRCC as evidenced by KEYNOTE 427 and other datasets. Combination therapy is superior, however, so dose interruption/modification of the TKI should be attempted before discontinuing permanently.
How do you manage a patient with superficial venous thrombosis with close proximity (<3 cm) to deep veins and an inherited thrombophilia ?
I would treat the patient for 3 months with a DOAC and then repeat the scan. If the clot is resolved, I would order a d-dimer and Factor VIII level on anticoagulation. If the tests are negative, I would stop the DOAC and retest at 30, 90, and 180 days. If tests remain negative then stay off anticoag...
How do you approach decision making in terms to adjuvant chemotherapy after CSI in adult medulloblastoma?
Medulloblastoma is a chemotherapy sensitive disease. The NCCN guidelines have options for CSI alone or followed by chemotherapy for standard risk disease (M0, residual disease <1.5cm2, classic or desmoplastic histology) and recommend post-CSI chemotherapy for high risk disease. Unfortunately, 25% of...
How do you manage anaplastic thyroid cancer that is progressing through radiation therapy?
The algorithms for ATC, a rare disease, have gotten relatively complex including the incorporation and timing of XRT. It is unclear from the question what the presentation scenario is, i.e., localized disease or metastatic, and the mutational status, as ideally at a minimum BRAF status is known. Now...
Do you use breast cancer index (BCI) in patients with 1-3 node positive ER+/HER2- IDC?
The only clinical case where I would consider ordering a BCI in a female patient with 1-3 positive lymph nodes would be in a postmenopausal woman who is considering to take adjuvant tamoxifen for 10 years vs 5 years based on the aTTom trial (Bartlett et al., PMID 31504126).I do not order BCI in othe...
Would you give EP chemotherapy to a patient with Stage IIA nonseminoma with negative markers who underwent RPLND and had pN2 disease with predominant teratoma?
For CS IIA disease undergoing open RPLND by an experienced urologist, the long time practice of the groups that I have the fortune to work with closely has been to not given adjuvant therapy since there is a substantial chance of obtaining cure with surgery alone without any chemotherapy. The upstag...