Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What adjuvant therapy would you offer a post-menopausal CHEK2+ patient with HR+ HER2+ T1bN1 breast cancer and concurrent HR+ HER2- T1N0 disease?
These are hard cases. In general, the HER2 positive disease will take priority. Although it would be ideal to have treated the patient neoadjuvantly to assess response and potentially offer adjuvant TDM-1 per the KATHERINE trial, for now, I would optimize her therapy with adjuvant TCHP for 6 cycles ...
How would you treat a patient with metastatic RCC who developed posterior reversible encephalopathy syndrome (PRES) on a TKI-containing regimen?
PRES is a clinical-radiological diagnosis. The pathology (to my knowledge) is not yet clearly defined though is thought to be the consequence of vascular permeability compromise. There are known triggers of this disease including chemotherapy, auto-immune conditions and VEGF-TKI therapy, and hyperte...
How would you treat a young patient with metastatic colorectal cancer who initially tolerated 12 cycles of FOLFOX + bev with disease progression after cycle 3 of maintenance 5-FU + bev?
TRIBE and TRIBE2 studies showed convincing evidence of triplet chemotherapy FOLFOXIRI/bevacizumab has PFS, and more importantly, OS benefits for patients with metastatic colorectal cancer (mCRC) and now, this regimen has been used in our routine clinical practice more and more frequently especially ...
What features help distinguish thyroid myopathy from immune checkpoint inhibitor-associated myopathy?
Immune checkpoint inhibitors (ICIs) can cause myositis (ICI-myositis). Since ICIs can also induce hypothyroidism, myopathy secondary from hypothyroidism can also be associated with ICI therapy. Different from thyroid myopathy, patients with ICI-myositis barely have myoedema or muscle pseudohypertrop...
For treatment of ITP, what would you add to dexamethasone to achieve the fastest recovery in a patient waiting for a procedure?
I usually use IVIG, particularly if the patient has responded in the past.
How do you approach patients with recurrent grade 3+ neutropenia on IMiD-containing regimens (e.g., VRd or KRd) beyond dose reductions?
IMiD dosing is a challenge. Let's start with what we know: The FDA approved dose of thalidomide is out of date and the OPTIMUM trial suggests 100 mg PO qHS is the "best" dose (Kropff et al., PMID 22133776) because 400 mg is far too toxic. The phase 1 of Pomalidomide does not demonstrate superiority ...
How would you treat a patient with metastatic renal cell cancer with Crohn's disease after failing available tyrosine kinase inhibitor therapies?
It is not an absolute contraindication! It depends on how active the Crohns is; what therapy he is on for the Crohns. Patients on auto immune disorders treated with IO have about a 30% chance of a flare. In RCC, prior to the availability of CPI, monotherapy with sequential TKI's was the standard an...
What chemotherapy do you use with radiation for urothelial carcinoma with squamous differentiation?
In case of primary or dominant urothelial carcinoma with squamous cell features, would approach similar to pure urothelial carcinoma and consider same radio-sensitizing chemo that we are using in S1806 phase III trial. Doses below may not fully reflect S1806 protocol and also depends on the patient ...
How would you approach therapy for BR-refractory Waldenstrom Macroglobulinemia when there is a mixed response to zanabrutinib?
It goes without saying this is a “data-free zone.” I would consider extrapolating from CLL and adding venetoclax.
What are your recommendations for a patient with metastatic non-mutated lung adenocarcinoma who previously had headaches responsive to prednisone but with negative temporal artery biopsy for GCA?
GCA is often a challenging diagnosis to make in the absence of objective findings of halo sign, pathologic evidence of vasculitis, or large vessel vasculitis on imaging. Headache of any type will often respond to prednisone so the first step, in this case, is to determine if the patient truly has GC...