Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What is your approach to prescribing gabapentin for oral mucositis prophylaxis during chemoradiation?
It can be a useful adjunct therapy, especially for patients getting radiation for oral cavity cancer. Randomized trials have been conflicting but some have shown benefit in a prophylactic setting. In my experience, patients tend to need less narcotic medication (usually able to get by with gabapenti...
What is your approach to treating inoperable mucosal melanoma of the head and neck region?
It is often nasal cavity/paranasal sinuses, so 1.2 Gy BID to 74.4 Gy and electively treat the neck. Otherwise 70 Gy/35 fx/30 treatment days SIB.
Do you have a maximum size cutoff for lung SBRT in central NSCLC?
The bigger the tumor size, the lower the efficacy of SBRT. Typically, I wouldn’t treat lesion of size >7 cm for the following reasons: The local control is lower even with BED>100 Gy; There is high chance that the PTV overlaps with critical structures so toxicities could be high. There is high poss...
How do you choose which BTK inhibitor to use in NHL?
At this point, I use very little ibrutinib. If I need CNS penetration, ibrutinib has a track record there. Otherwise, I have pivoted to acalabrutinib and zanubrutinib. I typically will pick by indication - acala for CLL and zanu for WM/MZL. In MCL or likely soon in CLL, I am not entirely sure how to...
How do you choose which BTK inhibitor to use in NHL?
At this point, I use very little ibrutinib. If I need CNS penetration, ibrutinib has a track record there. Otherwise, I have pivoted to acalabrutinib and zanubrutinib. I typically will pick by indication - acala for CLL and zanu for WM/MZL. In MCL or likely soon in CLL, I am not entirely sure how to...
Would you re-challenge a CLL patient, who had good response to Zanubrutinib but contracted cryptococcal pneumonia, with another BTK inhibitor?
Infections are part of the natural history of CLL. While cryptococcal meningitis is the uncommon one in CLL, it does occur when these patients are on steroids, have prior receipt of fludarabine, bendamustine, or other treatments which suppress the cellular immune system (in particular CD4+ T-cells)....
Would you re-challenge a CLL patient, who had good response to Zanubrutinib but contracted cryptococcal pneumonia, with another BTK inhibitor?
Infections are part of the natural history of CLL. While cryptococcal meningitis is the uncommon one in CLL, it does occur when these patients are on steroids, have prior receipt of fludarabine, bendamustine, or other treatments which suppress the cellular immune system (in particular CD4+ T-cells)....
For patients who meet criteria to be treated with 3 months of CAPEOX based on IDEA study, is it reasonable to use capecitabine alone for 3 months and drop oxaliplatin during the COVID pandemic?
This is indeed a question for our times. There are no data to support three months of capecitabine. In fact, the studies that suggest the single agent fluoropyrimidine carries more of the benefit than oxaliplatin are all based on six-month trials. While single agent capecitabine may be necessary if...
How would you manage a well differentiated neuroendocrine cancer without a known primary that is not clearly resectable but not overtly metastatic?
NENs of unknown primary are relatively rare, and they constitute less than 5% of all CUPs. Previous series review showed that NENs with an unknown primary site account for 10-14% of all NENs. Most of them present with liver mets, and a majority of these represent gastroenteropancreatic NETs. Clinica...
What parasites do you screen for in your workup of HES?
In my practice, if GI symptoms (particularly diarrhea), then culture for stool ova and parasites (broad screen). If there are no GI symptoms, then only screening for Strongyloides with a blood test for Strongyloides antibody. If there is a recent travel history or a patient immigrated from areas wi...