Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach duration of immunotherapy in patients with metastatic NSCLC?
If someone manages to continue the ICI maintenance up to 2 years without progression, I am comfortable counseling the patient to stop the ICI treatment as per the regulatory approval indication. I have had occasionally, patient's anxiety level driving the desire to continue beyond the 2 years treatm...
For muscle-invasive bladder cancer with predominant (>90%) squamous differentiation, would you consider cisplatin-based neoadjuvant chemotherapy prior to radical cystectomy or upfront surgery?
While muscle-invasive bladder cancer (MIBC) patients with a minor variant histology component are treated similarly to conventional urothelial carcinoma (i.e., neoadjuvant cisplatin-based combination followed by surgery), there are no definitive data to guide the perioperative systemic therapy of th...
When giving FOLFOX/FOLFIRI and skipping 5FU bolus, do you still give leucovorin?
In general, if I am not giving the 5-FU bolus, I will also not give the leucovorin. The purpose of the leucovorin is to increase the time that 5-FU given by bolus binds to thymidylate synthase. Since the 5-FU bolus is being withheld, the leucovorin has limited purpose, as the 5-FU continuous infusio...
Would you consider starting immunotherapy concurrently with whole brain radiation for newly diagnosed metastatic (BRAF negative) melanoma with multifocal symptomatic brain metastases?
This is a challenging clinical situation. In part, the approach depends on the number and size of the CNS lesions. However, I do not recommend the use of WBRT for my patients, as it has not demonstrated a survival benefit. In addition, in the adjuvant trial comparing WBRT to observation, it did not ...
For patients with recent post-delivery symptomatic ovarian vein thrombosis on anticoagulation, how would you approach periop AC management for upcoming procedures like D&C?
Nevertheless, I would first determine if the D&C needed to be performed so soon after diagnosis of the ovarian vein thrombosis or if it could be delayed. If it needs to be performed sooner, communicate with the proceduralist to determine if the anticoagulation needs to be interrupted. A number of in...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
What is your threshold to diagnose light chain MGUS with only a slight elevation in the light chain ratio, in a patient without other CRAB symptoms and no M spike?
Mild increase in kappa light chains can be a result of antigenic drift seen with the assay, in renal dysfunction both can go up but kappa may go up a bit more skewing the ratio. If a 24-hour urine with electrophoresis and immunofixation is negative and the rest of the work up is negative, would cont...
How do you choose a neoadjuvant therapy regimen for a patient with a triple negative breast cancer and a synchronous ER-/Her2+ breast cancer?
Assuming there is no contraindication to administration of an anthracycline, I would favor weekly paclitaxel and weekly carboplatin with every 3 week trastuzumab and pertuzumab x 12 weeks followed by ddAC x 4. This gives the TNBC the benefit of the higher pCR rate seen with the addition of carboplat...
Would you consider enfortumab vedotin + pembrolizumab prior to surgery for a patient with urothelial carcinoma with regional nodes who is not eligible for neoadjuvant cisplatin?
The appropriate management for LN+ bladder cancer is not clear, and whether or not to use EV+pembrolizumab in this setting is also without significant data. Clinically and practically, there are so many gray areas in this question that the best path is at best charcoal-colored. Generally, systemic t...