Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When do you recommend patients get vaccinations with respect to their RT course?
I agree with @Dr. First Last's reply, and find that some patients are under the impression they are immunocompromised during radiation therapy and thus should avoid vaccines, when in fact the opposite is true. The skepticism behind the science of vaccination also can lead to avoidance, and so I try ...
Would you offer neoadjuvant chemotherapy to premenopausal women with cT1cN0 HER2+ breast cancer?
Since most neo-adjuvant trials required that primary tumor was at least 2 cm, I tend to lean towards upfront surgery. If the tumor size is confirmed and sentinel lymph nodes are negative, the patient could be offered paclitaxel and trastuzumab which is significantly less toxic than pertuzumab in com...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
This is an interesting question. Based on personal communication (Italy, Germany, Israel), we have not seen increased risk for pediatric patients with hematological diseases and COVID-19. There was one case reported in China, but it was inconclusive (nearly 50 y.o. patient with aplastic anemia—seeme...
What neoadjuvant strategies do you utilize for initially unresectable biliary tract cancer?
Great question. While there is not prospective data, I tend to use the triplet chemo regimen of gem/cis/nab-paclitaxel based on the 20% conversion rate seen in this phase 2 study. There is an ongoing neoadjuvant study in IHCC that is investigating the triplet, but this is only open at select centers...
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
How do you approach a patient with IgM monoclonal gammopathy associated with severe neuropathy of unclear etiology?
I usually confirm if the patient does not have AL Amyloidosis or POEMS, and as part of work up for IgM MGUS, I order MYD 88 mutation. If all are negative and I still believe that neuropathy is caused from his/her MGUS, you can try IVIG for the neuropathy as a trial (of course after using gabapentin,...
Should cisplatin, gemcitabine, and veliparib be the standard of care in treating metastatic/unresectable pancreatic cancer with BRCA or PALB2 mutation?
In a recent publication (O’Reilly et al. JCO 2020), the authors reported high response rates (74.1% vs. 65.2%, respectively) of both study arm (gemcitabine + cisplatin + veliparib) and control arm (gemcitabine + cisplatin) from a phase II open-label, randomized multicenter trial. Despite the unprece...
How long after lumpectomy for DCIS in a premenopausal patient can tamoxifen be started and still retain the benefit?
The TAM-02 trial showed that women with IDC who delayed taking tamoxifen 2 or more years after their diagnosis still did better than those who did not initiate it at all. You can extrapolate this data to ER+ DCIS as the protective benefit of estrogen blockade on breast tissue occurs whenever it is s...
How do you manage neurocognitive decline associated with chemotherapy (i.e. chemo brain)?
I agree with @Dr. First Last's detailed response. Practically speaking, I would also add that it is important to listen and validate your patient's concerns and respond to their frustration and sense of loss. A diagnostic evaluation will not only help you and your patient discover or 'rule out' othe...
Do you offer fertility preservation to patients prior to CAR-T therapy?
There is no evidence yet about the impact of CAR-T itself on fertility, and this will be difficult to study in isolation in this population. Many CAR-T patients have been heavily pre-treated, so semen cryopreservation and oocyte harvesting may not be successful; but if feasible they should be attemp...