Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your recommended treatment sequencing strategy in patients with HER2+ breast cancer and leptomeningeal carcinomatosis?
HER2+ breast cancer and leptomeningeal carcinomatosis is a very challenging situation but we have more options than ever before. While the DB-12 study excluded patients with leptomeningeal metastases, T-DXd (trastuzumab deruxtecan) has shown excellent activity in retrospective series and small prosp...
What is your general approach to PARPi usage in the front-line and recurrent ovarian cancer setting in light of FDA label changes over the years?
In the frontline setting, I generally recommend PARP inhibition with olaparib x2 years for BRCAmut patients (1) and with niraparib x2-3 years for patients with HR-deficient tumors (I personally tend to do 2 years, based on SOLO1 data with olaparib) (2). For BRCAwt patients with HR-proficient tumors...
For the neoadjuvant treatment for thymoma, when do you favor CAP with prednisone over CAP?
Yes, due to the MD Anderson trial that used CAP+prednisone. However, there are no randomized data. I use carbo-taxol for thymic carcinoma.
What is your approach to the management of unprovoked distal DVTs?
The management of distal deep vein thrombosis (DVT)—[involving the peroneal, posterior tibial, anterior tibial, or the muscular calf veins (gastrocnemius and soleus); proximal DVT, by contrast, refers to thrombosis in the popliteal, femoral, or iliac veins]—is evolving in step with broader changes i...
For concurrent chemoradiation in head and neck cancers, how important is the timing of weekly radiosensitizing cisplatin early versus late in the week?
Our protocol for concurrent cisplatin-RT demands that the drug will be infused 1-2 hours before RT, usually on Mon. The assumption is that it will allow maximal drug concentration in the cancer cells at the time RT is delivered after chemo on that day, early in the week, while some radiosensitizatio...
How would you approach escalation of therapy in an adult patient with refractory Still’s disease and associated MAS/HLH (ferritin >100,000, transaminitis, DIC) despite high-dose steroids, high-dose anakinra, tocilizumab, and ruxolitinib?
Emapalumab is an appropriate escalation in the described circumstance. I have no experience, and there is little published data as of yet with MAS825, but I would position this as an option to pursue before using etoposide. While there may be an indication of confounding, etoposide use nonetheless h...
What is your approach to IV fluid resuscitation during a sickle cell vaso-occlusive crisis?
My approach to IV fluid resuscitation in vaso-occlusive crisis is cautious and individualized. Adequate hydration is important to prevent further sickling, but I avoid aggressive fluid loading because of the risks of pulmonary edema and acute chest syndrome. I typically use isotonic balanced crystal...
In a pregnant patient with PNH without aplastic anemia who has residual hemolysis while on ravulizumab and on prophylactic LMWH, what else can be done to reduce thrombotic risk and improve maternofetal outcomes?
Personally, I feel that C5 inhibitors are now close to obsolete in the management of PNH, since C3 and factor B inhibitors are more effective and inhibit both intravascular and extravascular hemolysis. Whether or not to use pegcetacoplan or iptacopan depends on the trimester, the seriousness of the ...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...
How do you manage anticoagulation for patients with DVT/PE who have brain metastases?
Not all brain metastases pose the same risk to patients. Rapid, numerous (even if tiny), new onset metastases from RCC or melanoma (especially BRAF mutant) can go from asymptomatic to life threatening hemorrhage within 1-2 weeks and I would strongly caution anti-coagulation in these patients. If the...