Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
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?
Yes, using IL-6 drugs is a good option for the patient with GCA post ICI. I think theoretically we should be able to continue immunotherapy and biologic therapy such as tocilizumab, but we do not have evidence and insurance companies have not been very amenable. The goal of my research is to ensure ...
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.
Would you offer neoadjuvant chemotherapy to cT1c N0 triple negative breast cancer with metaplastic features in a young patient?
I would argue to proceed with neoadjuvant chemotherapy in this patient - as one could monitor anti-tumor response and offer capecitabine if residual disease. As not a T2 tumor, this patient does not fit the criteria for the KEYNOTE-522 regimen. One may also consider hereditary genetic testing for th...
How long do you continue temozolomide in a patient receiving capecitabine/temozolomide for well-differentiated neuroendocrine tumor?
The true answer is that we do not know. There is no question the CAPTEM combo is effective and the highest quality data comes from ECOG E2211 which was just updated at this year's ASCO. In that trial, patients received up to 13 cycles. In the past, there was the temptation to continue CAPTEM as long...
If a patient had a grade 2 infusion reaction to initial dose of IV Rituximab, can you give subcutaneous Rituximab for cycle 2 or continue with IV Rituximab?
I would likely continue IV rituximab until no more infusion reactions are observed before switching to SQ.