Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How are you approaching patient selection and timing of RNA-based NGS, in light of the approval of zenocutuzumab for NRG1 fusion–positive advanced cholangiocarcinoma?
My standard has been to do all DNA, RNA, and IHC through a single vendor. I test all newly diagnosed patients with cholangiocarcinoma. I always do tissue and liquid biopsy NGS. If tissue biopsy is not feasible because of sample quantity/quality, then another biopsy will be the way to go to obtain, e...
What is your approach to iron deficiency anemia after a negative EGD and colonoscopy?
Cross-sectional imaging is the next step to evaluate the small intestine, which cannot be easily assessed by standard endoscopy. This will show whether there are masses or inflammation, and, if you do a triple-phase CT, whether there are large vascular lesions that could be the source of bleeding. A...
Would you add immunotherapy to FOLFOX if the patient is not a FLOT candidate for neoadjuvant gastric cancer, extrapolating data from the MATTERHORN study?
While it is always somewhat perilous to extrapolate from a proper study to lesser situations, this seems quite reasonable. It seems highly unlikely that the removal of Taxotere from a fluoropyrimidine-oxaliplatin-based regimen would render immunotherapy less effective in gastric cancer. In the MATTE...
How do you interpret recent large retrospective analyses comparing radical prostatectomy vs. radiation for prostate cancer?
There have been numerous comparisons of RT vs. RP from a variety of study teams with various conclusions, and it often seems like the principal conclusion of the study is best predicted by the subspecialty from which the authors originated (urology vs. radiation oncology). As the question partially ...
How would you approach a patient with HR+, HER2- metastatic breast cancer who is endocrine resistant, with bone marrow involvement and pancytopenia?
Symptomatic bone marrow involvement (bone marrow carcinomatosis) is extremely rare in metastatic breast cancer and carries very poor prognosis. It is often associated with microangiopathic hemolytic anemia and DIC. Anemia is the most common manifestation and WBC and platelet counts are often not tha...
Are there any contraindications to Pluvicto therapy you personally use, given that there are none directly provided by the manufacturer?
In this situation, it is helpful to review the eligibility and exclusion criteria from the VISION protocol directly. These can be found at NCT03511664 (Sartor et al., PMID 34161051). Many of these patients have been heavily pretreated, including prior taxane therapy, so my main concern is that they ...
How would you integrate immunotherapy into the treatment of a patient with recurrent, widely metastatic gastric adenocarcinoma after initial treatment with perioperative EOX and subtotal gastrectomy?
I agree with my friend, @Dr. First Last. Firstly, I hope that this is an entirely theoretical scenario or that the patient received EOX many years ago, prior to the FLOT4 data that established FLOT as the current standard-of-care. As Dan also mentioned, for patients who cannot tolerate FLOT, FOLFOX ...
In which patients do you utilize a breast MRI as part of the initial workup for breast cancer?
I'm not a fan of routine MRI in the work-up for early-stage breast cancer, but I do agree with the fairly standard list of selective indications mentioned previously. I also obtain an MRI when there is a significant discrepancy between standard imaging and physical exam. Examples would be: One or a...
How, if at all, have you incorporated GLP-1 agonists into your fertility-sparing management of patients with EIN or endometrial cancer?
While ultimately not a fertility-sparing use, we have begun to use GLP1s in conjunction with dietetic consult, weight loss medicine, and exercise in an attempt to convert patients with medically inoperable endometrial cancer to operability when the only major contraindication is morbid obesity in yo...
How do you manage patients with atrial fibrillation having a thromboembolic infarct despite being on adequate anticoagulation?
This scenario is always challenging. In terms of anticoagulation, the efficacy of DOACs in preventing embolic events in AF patients is around 70%, which is impressive compared to warfarin but not foolproof. In cases of a second embolic event while on anticoagulation, two reasonable approaches are of...