Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is the optimal duration of therapy in patients with metastatic colon cancer with no evidence of disease?
First of all, it sounds as if congratulations are in order for your management (to have sustained a patient with mCRC for over 5 years is truly a remarkable accomplishment, although in cases like this the self-pitying oncologist might wonder if they are victims of their own success in determining a ...
Is there a threshold absolute neutrophil count for which you would consider holding radiation?
I don't have a threshold dose for holding radiation. This decision is based on the etiology of the leukopenia. If the patient is receiving concurrent chemoradiotherapy it is usually the chemotherapy causing the issue and I rarely hold radiation even with ANC < 1000. If one were to hold both the chem...
What factors do you consider when you are deciding whether to recommend endocrine therapy for a woman who has had a mastectomy for DCIS for contralateral breast cancer risk reduction?
Endocrine therapy after a mastectomy for DCIS is primary prevention, and therefore elective. I present this as an option to decrease contralateral breast cancer risk. I quote that risk as approximately 0.7% chance per year. I generally don't recommend it for older patients or to patients with HR-neg...
What adjuvant therapy would you recommend for a cisplatin and IO ineligible patient with node positive urothelial carcinoma with mixed histology?
This is a difficult situation and I agree that there is evidence for adjuvant carboplatin-gemcitabine in cisplatin-ineligible patients with high-risk upper tract urothelial carcinoma, although benefit appeared more modest compared to cisplatin-gemcitabine (POUT trial). It is reasonable to extrapolat...
What first line therapeutic regimen do you consider most appropriate for metastatic clear cell renal carcinoma presenting with brain metastasis and vasogenic edema?
Yes, it is safe, but I always treat the CNS metastasis first (e.g. SRS). The risk of bleeding in an untreated CNS metastasis with a VEGF TKI is otherwise unacceptable in my opinion. The edema should be treated with steroids as appropriate and I haven't experienced TKIs worsening CNS edema.
Do you treat muscle-invasive urothelial bladder cancer with plasmacytoid features any differently in terms of the recommendation for neoadjuvant cisplatin-based chemotherapy?
Plasmacytoid variant carcinoma is a rare aggressive variant that tends to be chemosensitive but recurs frequently and is characterized by CDH1 loss of function genomic alterations and peritoneal metastasis. In predominant plasmacytoid urothelial carcinoma, the role of neoadjuvant chemotherapy (NAC) ...
How do you decide between radioligand therapy or cytotoxic chemotherapy in patients with metastatic castration-resistant prostate cancer with prior ARPI exposure who have cancer-related anemia?
Radioligand therapy (presumably the question refers to Lu-177 vipivotide tetraxaten/Pluvicto) is one of the latest and most promising treatments for mCRPC. As in all cancer treatments, the practitioner needs to have a good understanding of adverse event likelihood, but also the potential for benefit...
What is the optimal management of a patient with refractory TTP who has had poor response to plasma exchange, steroids, rituximab, especially when caplacizumab is unavailable?
Caplacizumab would obviously be the best thing right now, but if unavailable, there are some data with cyclosporine as well as bortezomib and cyclophosphamide to help with more refractory disease. These measures, unfortunately though, will take some time to have an effect. Intensification of plasma ...
Would you offer any adjuvant therapy for a young patient with anal cancer s/p definitive chemoradiation and R0 resection with significant residual disease?
We do not have complete details regarding the clinical history of this case. For instance, information about the patient’s initial response to chemoradiation—whether residual disease was identified early or if this represents a local recurrence after an initial favorable response—would be important ...
How do you reconcile discrepancies in clinical prostate cancer staging with AJCC and NCCN?
Fundamentally, I use NCCN risk categories to help steer conversations about staging and treatment options for very low vs low vs fav int vs unfav int vs high risk diseases. Therefore, I use NCCN staging in my clinical practice and notes and incorporate mpMRI into staging. I find it comforting that N...