Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you decide between anticoagulation or portal vein recanalization in a patient with portal vein thrombosis?
It depends on cirrhotic vs non-cirrhotic. For cirrhotic, best to reference the AASLD 2020 guidance here - Northup et al., PMID 33219529.For non-cirrhotic: important to determine the etiology as well as evaluate for a hypercoagulable state, including checking for JAK2 and CALR.If acute and non-occlus...
How do you manage toxicities in patients with mPDAC receiving daraxonrasib?
In our experience, we have found several strategies effective: Rash: Doxycycline 100 mg twice daily, avoid all sun exposure and use sunscreen, apply hydrocortisone 2.5% twice daily to face and upper chest and back and neck apply emollient moisturizer to arms, legs, hands, feet at least twice daily....
How do you approach the risk/benefit discussion for IV iron in a patient with concomitant severe iron deficiency and elevated hematocrit due to supra-physiologic testosterone supplementation?
I only administer iron if symptomatic (pagophagia, RLS, etc). I have not seen iron deficiency with testosterone prior to phlebotomy. When it is required, I literally walk both sides of the aisle. If a non-phlebotomized patient presented with ID, I would work it up like any other. If I have to treat,...
For iron deficiency anemia due to heavy menstrual bleeding, what is your preferred method of controlling heavy menses?
I definitely loop in my GYN friends for this one! According to ACOG: "Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life." The consequences of HMB are substantial and multifaceted, and, as we f...
For patients with metastatic cancer on a systemic therapy regimen that includes bevacizumab, are you comfortable treating brain metastases (SRS or WBRT) without holding bevacizumab?
Multiple prospective trials have demonstrated the safety of combined bevacizumab and radiosurgery (from both recurrent GBM and brain mets) with some data to actually demonstrate a protective effect against radionecrosis. No significantly increased synergistic risk of intracranial bleed has been obse...
Do you perform EBUS-TBNA for staging in patients with biopsy proven malignant lung nodules with no lymphadenopathy on CT chest and PET scan?
I agree that incidence is low, but estimates for radiographically occult nodal disease range from 10-20% and the fact is there isn't great literature on this. A PET scan is a decent test, better than a regular CT, but there are still a significant minority of patients that are mis-staged when an EBU...
Do you offer local consolidative therapy for patients with polymetastatic driver mutation-positive NSCLC who respond well to targeted therapy?
This is a great question. In phase II prospective study, Gomez and colleagues (Gomez et al., PMID 31067138) demonstrated a PFS and OS benefit with local consolidative therapy in patients whose disease did not progress after first-line systemic therapy. In my opinion, local consolidation therapy to o...
How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?
Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.
Will you extrapolate EORTC 1333/PEACE-3 (enzalutamide + Rad223) to any other ARPIs for mCRPC?
Abiraterone is contraindicated in combination with Ra-223, based on the ERA 223 trial, which showed a substantial increase in fracture risk in combination with Ra-223 (29% vs. 11% with abiraterone alone). However, other ARPIs also increased fracture risk compared to ADT alone, although the extent of...
How would you approach the management of a patient with Stage IV NSCLC harboring both a classical and non-classical compound EGFR mutations?
I was asked to dust off q prior Mednet discussion on frontline treatment selection for patients with a new diagnosis of advanced common EGFR mutation+ NSCLC in light of recent updates on both the key FLAURA2 and MARIPOSA trials. And indeed the timing seems ripe for such not just due to these updates...