Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How many days do you hold osimertinib during or around SBRT for oligometastatic EGFR mutated advanced lung cancer?
This a great question and a common clinical scenario that we are all confronted with. Stereotactic body radiation therapy (SBRT) is being increasingly used for oligometastatic progression of EGFR mutant NSCLC. The theoretical risk of combining EGFR inhibitors and radiation therapy would be an enhanc...
What scenarios, if any, are you delaying adjuvant chemotherapy in light of the COVID-19 outbreak?
This is a complex issue that our group here at MSKCC is dealing with right now, with formalized guidance pending. This is in mind of the fact that the mortality rate in Chinese patients with cancer approached 6%. While I wouldn't delay starting adjuvant therapy—which is being given with curative int...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
How do you decide whether to hold acalabrutinib or zanubrutinib in patients with indolent B-cell lymphoma/leukemias in a perioperative/periprocedural setting?
This is always a point of discomfort among providers, but it can actually be made quite easy. BTK inhibitors have known antiplatelet effects similar to low-dose aspirin. Consequently, if the surgeon holds aspirin for the planned procedure, I generally recommend that we hold the BTK inhibitor for 3 d...
For patients starting Pluvicto, do you have patients stop their ARPI?
While the VISION trial allowed for concomitant use, it was only about half (53%) in the Lu-177-PSMA arm, and 2/3 (68%) of those on the standard of care arm - Garje et al., PMID 36693228. And the PSMAfore trial did not, as noted above by @Dr. First LastThe bigger question is, will you continue the AR...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...
Do you check IGHV mutation status in patients with newly diagnosed CLL?
Yes. In the targeted therapy era, there are three factors that continue to have prognostic and therapeutic significance and should be checked: IgHV mutation status p53 aberrancy - requires both FISH for del17p AND mutation analysis for p53 Complex karyotype - can be done on peripheral blood or marr...
What adjuvant chemotherapy would you recommend in an elderly patient with resected stage III colon cancer with MMR deficiency with MLH1 promoter hypermethylation?
This is a great question and actually a quite common situation we see in the clinic. Majority of the dMMR colorectal cancer is actually due to MLH1 promotor hypermethylation (about 75% of all dMMR colorectal cancer) while a small portion of dMMR colorectal cancer is due to Lynch syndrome. These pati...
Is there any indication for IVIG in immunocompromised patients with only decreased IgM and/or IgA levels?
Nope. IVIG preparations contain IgG not IgA or IgM. Low serum IgA may or may not be associated with low IgA levels in mucosal surfaces leading to a risk of local infections. Low levels of one or both may be asymptomatic but in the right setting might suggest a need for evaluation of plasma cell dysc...