Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there any role for early stem cell mobilization and collection during the SMM phase?
Prolonged exposure to lenalidomide can affect the ability to mobilize and collect stem cells, though this is less of an issue with increasing use of plerixafor (Giralt et al., 2009). If you are going to treat with an IMD, it is important to collect stem cells after 4-6 months of therapy, similar to ...
When discussing immunotherapy with patients, how do you frame the conversation in a way that acknowledges the fact that many patients do not respond but allows for hope for a durable response?
There is certainly more than one way to do it. The best way depends on knowing the learning style and information preferences of your patient and then tempering information that they need to have to be informed appropriately. The Shared Decision Making [SDM] model encourages us to invite the patient...
Would you recommend sentinel lymph node biopsy at the time of wide excision for a 3 mm Merkel cell carcinoma of the cheek/lateral canthus?
Unlike melanoma and certainly NMSC, MCC is highly unpredictable in nature, with clinical lesion size having little clinical prognostic value. As such, it appears that SLNB is valuable in many cases for the purposes of prognosis and in determining the need for adjuvant systemic therapy and radiation....
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...