Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When, if ever, do you incorporate a dental evaluation before initiating Dato-DXd to offer guidance on oral care and help limit oral toxicity?
A formal dental evaluation can be considered, but it is unclear whether it is necessary before starting Dato-DXd. Proactive dental evaluation, when feasible, should be used, but evaluation should not delay the start of treatment. The use of good daily oral hygiene, including salt/bicarbonate and Bio...
What clinical and pathological features are you using when selecting patients for adjuvant cemiplimab in high-risk CSCC, given the differences between trial inclusion criteria and NCCN guidelines?
Identifying the select patient population who benefits from adjuvant cemiplimab for cSCC is critical. Current staging systems for cSCC are inadequate to specifically identify the tumors at highest risk for relapse and disease-specific death. The majority of high tumor category and 'high risk' cSCC a...
How do you treat non-spine bone oligometastases?
Get the MRI. It is proven to reduce inter-observer variability in contouring (Raman et al., PMID 29748100). More philosophically, sometimes you'll see something more, sometimes you won't. But the only way to know is to check. And if this treatment is worth doing, it's worth doing accurately -- espe...
In pediatric patients with Hodgkin lymphoma who have a partial response after chemotherapy and multiple disease sites above and below the diaphragm, how do you approach radiotherapy planning considering cumulative dose and toxicity?
RT dose and target volume in pediatric Hodgkin lymphoma are determined according to the systemic therapy protocol being used. For example, your case suggests a patient with Stage III or IV disease. In the COG study AHOD1331, patients received either Bv-AVE-PC or ABVE-PC systemic therapy x 5 cycles a...
How would you manage a patient with family history of protein S deficiency, now with provoked VTE and low protein S?
Low protein S would need to be checked at the appropriate time. It should not be checked during acute thrombosis It should not be checked while the patient is on DOAC If the provoking factor was estrogen containing contraceptives, testing should not be performed until the patient has been off of est...
What areas do you treat with RT for an intermediate or high risk pediatric Hodgkin Lymphoma with a slow early response?
For pediatric Hodgkin lymphoma, radiation fields are really based according to the treatment protocol. If the patient was being treated per AHOD 0031, then the radiation fields would include all sites of initial involvement, assuming they don't meet the criteria for omission of RT (RER and then a CR...
What is the optimal timing for PET/CT to assess disease and treatment response with nivo + AVD?
The S1826 study did not require interim imaging. Despite this, I routinely order an imaging test prior to cycle 3, day 1 for patients on the N-AVD regimen. In most cases, I order PET/CT scans. I continue therapy in patients with a Deauville score of 4 or less (partial or complete response) rather th...
What is the optimal timing for PET/CT to assess disease and treatment response with nivo + AVD?
The S1826 study did not require interim imaging. Despite this, I routinely order an imaging test prior to cycle 3, day 1 for patients on the N-AVD regimen. In most cases, I order PET/CT scans. I continue therapy in patients with a Deauville score of 4 or less (partial or complete response) rather th...
Do you favor 24 hour urinary metabolites over random urine collection when screening for MCAS?
In my practice, I currently use 24-hour urine metabolites. The 24-hour urine collection has been extensively validated and its use is supported by the literature (see review: Butterfield et al, PMID 35346887).That being said, a spot urine collection is now available and this is far more convenient f...
How would you work up a mildly neutropenic patient (ANC >800) with family history of neutropenia and personal history of occasional mouth sore?
The first question is whether to evaluate the neutropenia at all. With ANCs >800 and only occasional mouth sores, is a diagnosis necessary, and should the term “neutropenia” be used at all? If the family’s origin is in a part of the world where the Duffy null phenotype is common (e.g. Africa, parts ...