Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When a patient with pancreatic cancer received neoadjuvant chemo + chemo-RT, how do you manage an in-field, post operative positive margin?
The data from MD Anderson indicates that patients have a similar survival duration when they have an R1 resection after chemoradiation as when they have an R0 resection, and longer than expected with a positive margin. The Mayo Clinic also has data in rectal cancer where there may be an increased ri...
Do you routinely repeat imaging for PE after anticoagulation treatment to establish a new baseline?
We only do imaging if the patient is symptomatic still after a few weeks or has persistent chest pain or clinical signs of pulmonary hypertension. Rarely I have seen recurrent or progressive thromboembolic disease on anticoagulation. Another possible reason if the patient needs to go to surgery in t...
In which situations do you omit the 5FU bolus in FOLFOX or FOLFIRI?
This is a very commonly asked question in the clinic.The original studies all included leucovorin (LV) and bolus 5Fu as part of the regimen (FOLFOX, FOLFIRI). However, in the clinic, we know that the 5Fu bolus is the main reason that this patient has significant cytopenia and worse side effects from...
Do you prescribe respiratory muscle training (RMT) devices to patients with dysphagia?
We encounter dysphagia frequently in our patients with Parkinson's disease and other movement disorders. If there are any concerns about swallowing or aspiration, my first step is to refer to Speech Therapy for evaluation, and I defer to their expertise for specific treatments from there. That said,...
Do you intensify treatment for patients with double-hit lymphoma or double expressor lymphoma?
My personal practice is that I DO intensify therapy for patients with DHL but not necessarily with DE lymphoma. Generally, the "intensification" of choice is based on age. Young fit patients (for which there are few) with DHL are candidates for CODOX-M/IVAC or DA-REPOCH. Older patients (which the ma...
Would you consider adjuvant osimertinib for NSCLC with an EGFR E746_S752delinsV exon 19 mutation?
Yes. While some uncommon EGFR exon 19 deletions appear to be resistant to first and third-generation EGFR TKIs (e.g., L747P variant with higher IC50 requirements preclinically and associated with worse response/survival in case analyses), EGFR E746_S752delinsV appears to respond well to EGFR TKIs (W...
How do you manage fatigue in women receiving chemotherapy/hormonal/radiation therapy for breast cancer?
Managing fatigue is challenging for patients undergoing cancer therapy. One of the best ways to increase energy is to exercise. It is a bit of a catch 22, but if you explain to patients they can start out with small goals and there symptoms will improve that can help. A very important contributor to...
How would you manage an enlarging brain metastasis that has progressed in size three months after radiosurgery?
Before making a decision, I would want to know the tumor histology, SRS dose delivered, and whether the current site of progression is truly within the prior radiation field (using new MRI fused to the SRS plan in treatment planning software). If the lesion is within the high-dose region and the pat...
Would you add whole-pelvis radiation as MDT (metastasis-directed therapy) in a patient with 1 pelvic node and 2 osseous metastatic sites for castrate-resistant prostate cancer?
This patient would not fit the PEACE V-STORM eligibility criteria, since the trial excluded patients with distant metastases and did not include patients who were castrate resistant, so I do not think you can extrapolate the results to this patient. One could argue that what you propose to do (SBRT ...
In patients with HER-2 positive breast cancer on pertuzumab/trastuzumab with newly developed asymptomatic brain metastases only, do you wait 3 weeks after administration of the targeted therapy to deliver SRS?
In a recently published study from Italy, Ippolito et al., PMID 35053467 a total of 10 patients with 32 HER2+ breast cancer brain metastases were treated with concurrent fSRT (27 Gy in 3 fractions) and Pertuzumab. Necrosis was reported in only 1 of the 32 treated lesions. The study is small but the ...