Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you manage a patient with sickle cell disease during pregnancy?
I refer all pregnant women with SCD to maternofetal medicine/high risk pregnancy clinic for more frequent monitoring. I recommend a baby aspirin for preeclampsia prevention (see UK guidelines). I recommend folic acid 4 mg. If they do have iron overload, I do not recommend iron supplementation. For a...
How do you manage endocrine therapy for premenopausal women with breast cancer who are heterozygous for factor V Leiden but have no history of thrombosis?
This is a difficult situation given that the literature is contradictory on this topic. Both tamoxifen and a factor V Leiden mutation independently increase risk of thromboembolic events. It is unclear whether, together, they would be additive in conferring risk of thrombosis. Dr. Cuzick wrote a ver...
How do you manage endocrine therapy for premenopausal women with breast cancer who are heterozygous for factor V Leiden but have no history of thrombosis?
This is a difficult situation given that the literature is contradictory on this topic. Both tamoxifen and a factor V Leiden mutation independently increase risk of thromboembolic events. It is unclear whether, together, they would be additive in conferring risk of thrombosis. Dr. Cuzick wrote a ver...
What systemic therapy would you use in patients with gastric cancer who had a relapse after Durva-FLOT (MATTERHORN regimen)?
In the rapidly evolving era of more intensive perioperative therapy, the FLOT-durvalumab combination is quickly becoming the standard for good-performance patients who can tolerate triplet chemotherapy and have no contraindications to immunotherapy. What to do after recurrence will depend in part on...
Would you recommend PARP inhibitor maintenance for a BRCA wild-type, HRD+ advanced ovarian cancer?
We have a better understanding of ovarian cancer biology now, including the importance of germline and somatic BRCA mutations, as well as the role of homologous recombination deficiency (HRD) in tumors and the potential benefit of new therapies in the maintenance.Considerations for maintenance thera...
When screening for malignancy, do you order CT with contrast (or) both with and without contrast?
I think the best way to think about this is to assess what each scan shows. A CT with oral and IV contrast is very good for assessing details between soft tissues and blood vessels. A CT without contrast is better for assessing for renal stones and for fractures, especially small insufficiency fract...
How do you approach patients with metastatic uveal melanoma not a candidate for tebentafusp-tebn?
I perform genomics and try to find a clinical trial that fits the patient. Including local liver therapies, such as the Delcath catheter treatment if available. Isolated liver lesion could also be resectable, so I request a surgical opinion. If nothing is available, then I offer ipilimumab/nivolumab...
How do you approach a patient with recurrent VTE who develops VTE again after reduction of apixaban to 2.5 mg bid?
Several factors play into this decision for me. Is the patient obese? Obese patients tend to give me pause for dose-reduction of DOACs. As such, half-dose apixaban may have been relatively underdosed for an obese patient and I would not call it DOAC failure, rather I would increase the dose to usua...
What is the minimum duration to be on bicalutamide prior to starting GnRH agonist in de novo metastatic prostate cancer with significant bone disease?
The onset of action for bicalutamide is rapid--typically slightly more than a day to reach maximum/peak concentration. In contrast, the pharmacological effect of leuprolide is related to the time to testosterone suppression which occurs approximately 2-4 weeks after starting. So the time to testoste...
Why does NCCN still not recommend using circulating tumor DNA to guide adjuvant chemotherapy in stage II colon cancer when colon cancer experts are currently embracing the practice?
While I cannot speak to that panel itself, I can support the very rigorous process that all NCCN guidelines undergo, and I surmise that the reason why ctDNA is not yet recommended is because there is no consensus that: It is better than CEA and good quality cross-sectional imaging (see, for example,...