Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you consider use of PARP inhibitors in patients with metastatic breast cancer with moderate penetrance germline mutations such as CHEK2, ATM, RAD51?
In the Olaparib Expanded (TBCRC 048) study published by @Dr. First Last in JCO, there were no responses to olaparib in metastatic breast cancer with germline or somatic CHEK2 or ATM pathogenic variants (mutations). In contrast, responses were seen in metastatic breast cancer with PALB2 pathogenic va...
How does neoadjuvant chemo-immunotherapy impact your decision on hypofractionation/dose fractionation for locally advanced NSCLC, now getting RT alone?
If a patient has already received 3-4 months of a platinum-doublet chemotherapy during the chemo-immunotherapy phase, then it's always my preference to omit further chemotherapy and recommend RT alone. The rationale for this recommendation is that we don't administer additional chemotherapy to patie...
In a patient with metastatic prostate cancer on abiraterone planning to start Radium-223, what is the minimum interval between the last dose of abiraterone and the first dose of Radium?
Update, May 16, 2026. The context of the question changes based on recently published data. These include the safety of combining an androgen receptor pathway inhibitor (ARPI) with Ra-223 and the utility of this approach in the evolving practice of metastatic prostate cancer.Abiraterone has a half-l...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
How would you approach anticoagulation for a patient with acute bilateral pulmonary emboli related to malignancy, but with a concomitant cavitary lung mass experiencing episodic, small-volume hemoptysis?
This is an interesting question to which we need to apply the art of medicine, weighing the risks and benefits of treatment. The major fatal events in this exact scenario are: Recurrent PE from undertreatment. Sudden massive hemoptysis after aggressive anticoagulation. The physician's management s...
How long would you anticoagulate a patient with recurrent VTE who has ongoing risk factors for intracranial bleeding?
In general, my preferred agent outside of the inpatient setting in patients with a risk of intracranial bleeding is LMWH. In the inpatient setting, utilizing a bivalirudin or heparin gtt is most appropriate. I would monitor carefully, including potentially imaging 24 hours after the therapeutic anti...
Would you recommend the SOFT/TEXT adjuvant approach of ovarian suppression/AI in a premenopausal woman with high-risk disease who still desires to have a pregnancy?
In the SOFT trial, the disease-free survival impact of adding ovarian suppression to hormonal therapy was not statistically significant in the overall population, but was superior in higher risk patients, including those who received chemotherapy. While we typically do not guide treatment based on s...
Can immune checkpoint inhibitors be safely given in a patient with chronic GVHD?
If the patient has active chronic GVHD the risk-benefit ratio of immune checkpoint blockade needs to be carefully assessed since there are well documented instances of severe GVHD flairs or immune-related adverse effects - in a patient on chronic immune suppression and quiescent GVHD we recommend no...
Does high risk cytogenetics as a sole abnormality influence your treatment decision for smoldering multiple myeloma?
Several studies have looked at the prognostic factor of FISH abnormalities and risk of progression of SMM to active disease (Neben et al., 2013; Rajkumar et al., 2013). Deletion 17p and t(4;14) are associated with the highest risk of progression, with median time to progression of 24 months, as repo...
How do you approach and counsel women with high risk, early stage breast cancer requiring chemotherapy for whom fertility preservation is a major concern?
Fertility preservation is a major issue in survivorship for younger cancer patients. Discussion with a specialist regarding banking eggs or embryos as early as possible is important. Proven techniques such as embryo cryopreservation may not be available due to financial constraints or other issues. ...