Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What objective tools do you use to help determine if a patient is too high risk for anticoagulation to prevent stroke or DVT?
There are a number of risk scores, like HAS-BLED, that can be used, but I continue to use clinical judgment and shared decision-making. The excellent risk profile of NOACs and the availability of LAAO mean that I can usually come up with a solution for almost every patient that will protect them fro...
When (if ever) would you offer radiotherapy for renal cell carcinoma following nephrectomy?
There is no indication for any type of radiation after nephrectomy in resected RCC. Often a 'positive' renal vein margin is not a true positive, but rather an artifact of having a renal vein thrombus and this should be discuss with the Urologist and Pathologist and clarified in the report. Having sa...
How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?
There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event ...
Do you have a certain tumor size threshold in which you change chemotherapy recommendations for a small, triple negative breast cancer?
Breast cancer death from small tumors is often underestimated. In 2000, 0.92%, 4.0%, and 10.7% breast cancer-specific deaths were due to T1a, T1b, and T1c node-negative cancers, respectively, which increased significantly to 1.9%, 5.8%, and 14.7% by 2017. This is an interesting read on death from sm...
Is fetal monitoring recommended when administrating IV iron to a pregnant patient?
There is no evidence of fetal harm with IV iron, and recommending this is inconvenient and unnecessary, and it does harm as it discourages necessary care. Two guideline papers, Van Doren et al., PMID 38282557, and Benson et al., PMID 40306833, as well as Anemia in Pregnancy in UpToDate, support this...
Do you discontinue an aromatase inhibitor in a patient if they have a cardiac event while on the drug?
Randomized clinical trials and several meta-analyses that compared tamoxifen with aromatase inhibitors (Khosrow-Khavar et al., PMID 32065766 is a more recent one) demonstrated statistically significant increase in the rate of cardiovascular events in women taking aromatase inhibitors although the ab...
How would you approach the management of a patient with metastatic non‑small cell lung cancer who previously received whole brain radiation therapy three years ago and now presents with 20 new brain metastases on MRI?
How aggressive I would be depends on KPS (which sounds to be good in this case), the patient's extracranial disease status (which sounds to be controlled on current therapy in this case), plans from a systemic therapy perspective (will the patient continue on the same therapy and what was the patien...
How do you manage refractory myelofibrosis with thrombocytopenia, significant leukocytosis (>150), and ASXL1 mutation?
The answer to this question requires, first, that like any patient with a malignancy, this patient must be staged according to the clinical and laboratory data that define the clonal tumor burden of the disease in question, as well as its extent clinically. In the spirit of full transparency, my ans...
How do you manage refractory myelofibrosis with thrombocytopenia, significant leukocytosis (>150), and ASXL1 mutation?
The answer to this question requires, first, that like any patient with a malignancy, this patient must be staged according to the clinical and laboratory data that define the clonal tumor burden of the disease in question, as well as its extent clinically. In the spirit of full transparency, my ans...
In a patient with an EGFR exon 20 insertion mutation with stage IIIA lung adenocarcinoma, is there any experience using amivantamab + carboplatin + pemetrexed in a neoadjuvant fashion?
No. What is interesting is the use of not a chemoimmunotherapy neoadjuvant approach vs upfront surgery, since more likely than not, the EGFR exon 20 mutation offsets ICI efficacy.