Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In a patient with HR+HER2+ early breast cancer who is receiving adjuvant T-DM1 for residual disease, do you overlap endocrine therapy with T-DM1?
Yes, in the KATHERINE trial, endocrine therapy was started concurrent with the T-DM1, same with radiation as indicated. This is included I believe in the published supplement in KATHERINE. So...yes, both endocrine therapy and radiation are fine to start while on T-DM1.
In patients with early-stage follicular lymphoma undergoing definitive RT, do you approach grade 3a disease any differently than grade 1-2 (radiation dose, fields/margins, systemic therapy)?
Our philosophy is based on whether it is grade 3A or 3B. If it is 3A, then we treat like low grade lymphoma with RT (similar dose and principle) but if it is 3B, then treat with chemotherapy +/_ RT like diffuse large B cell lymphoma.
Is there evidence to support or argue against intermittent fasting for cancer patients?
This is a complex topic with many permutations of dietary interventions similar to fasting such as calorie restriction and “fasting mimicking”, but as it pertains to pure fasting, I know of a few small studies which characterize fasting around the time of chemotherapy infusions (Raffaghello et al., ...
How would you treat a primary angiosarcoma arising in the skull, excised with initial excisional biopsy?
I would try to get some more information first. Is this a cutaneous primary invading into skull, or a lesion arising primarily in the skull? Is there any evidence of violation (tumor or iatrogenic) through calvarium such that dura is threatened? I would stage with a careful skin exam for any cutaneo...
How does metaplastic thymoma histology impact your decision regarding adjuvant radiation?
This is a good question. I honestly have never seen this histology, and I help write the UpToDate thymoma section and am a thymoma enthusiast (meaning I like to read about it/treat it, not to have it). Thymomas really run the spectrum of aggressiveness, and the approach to them in the adjuvant setti...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Would you give immunotherapy after neoadjuvant gem-cis for bladder cancer if cystectomy is being postponed for months due to non-autoimmune/unrelated comorbidities?
Delay in cystectomy regardless of the use of neoadjuvant chemotherapy is associated with compromised survival outcomes (Chu et al., PMID 30840335) and if a patient receives neoadjuvant chemotherapy and is unable to undergo cystectomy for months due to comorbidities, there is no clear data to support...
In patients with perihilar cholangiocarcinoma eligible for liver transplant, what is the protocol for neoadjuvant chemo-RT, particularly when brachytherapy is not available?
There is a lot of variability in neoadjuvant regimens prior to transplant for hilar cholangiocarcinoma as outlined in the survey paper above. Institutional approaches for total dose, fractionation, and target volumes vary considerably. A couple of points to consider and some personal opinions - Phil...
What factors aside from progression do you consider most important in determining whether a patient with metastatic papillary thyroid carcinoma is radioactive iodine refractory?
RAI refractory or resistant is defined as: Progression despite adequate RAI RX within the prior year after therapy Tumor that does not take up RAI either on a diagnostic or post-therapy whole body scan
Does your evaluation of a young person with spontaneous upper extremity DVT vary as compared to lower extremity DVT?
The workup for a young adult with an upper extremity DVT differs for me in two ways: Venous thoracic outlet syndrome must be suspected and a careful history of repetitive overhead movements must be obtained. Consulting your vascular surgery team in these cases to ensure the anatomy does not put the...