Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
When, if ever, would you initiate chemotherapy for recurrent colorectal cancer based on a positive ctDNA assay alone, such as Signatera, in the absence of tumor on imaging or physical exam?
No. There are many ongoing trials to look at this question and stay tuned for a soon in press JCO review that will reference many of the studies but currently, no data to treat based on a positive test. I will be more mindful of surveillance i.e., a 3-month scan, for example.
How would you approach unexpected chemo breaks during planned neoadjuvant chemoradiation for esophageal adenocarcinoma?
Local regional failure compromises quality of life
How do you choose the appropriate first line treatment between everolimus, somatostatin analogues, or cytotoxic chemotherapy in patients with good ECOG PS and widely metastatic atypical carcinoid of the lung?
If the patient is not symptomatic from tumor burden, can start with somatostatin analogues and then add everolimus on progression. Cytotoxic chemotherapy for patients who have progressed on everolimus.
Would you recommend anticoagulation in subsequent pregnancies after symptomatic postpartum R ovarian vein thrombosis?
The 2018 ASH guidelines recommend the following: For women not already receiving long-term anticoagulant therapy who have a history of VTE, the panel makes the following recommendations: Unprovoked VTE (strong recommendation, low certainty): and provoked VTE, hormonal risk factor (strong recommendat...
What would you recommend as first line therapy for metastatic chromophobe RCC?
Albeit limited data, I favor an IO-TKI doublet for chromophobe RCC. The recent B61 trial with Len/Pembro showed a response rate in the 25% range for this historically IO non-responsive subtype. I think all patients should get an IO-based regimen up front as no other regimens have curative potential....
How do you treat metastatic large cell neuroendocrine carcinoma of prostate with undetectable PSA, who had the treatment related transformation while on ADT monotherapy?
Treatment-emergent (or extra-pulmonary) high-grade neuroendocrine carcinoma (sometimes labeled HG-NEC or EP-NEC) is an increasingly seen phenomenon with the more widespread use of ARSI in the first-line setting. This is a distinct entity from prostate adenocarcinoma with neuroendocrine differentiati...
Do you offer adjuvant pembrolizumab post metachronous oligometastatic resection of RCC beyond the first year of diagnosis?
For patients with recurrence beyond 1 year of initial nephrectomy, I would not offer post metastasectomy pembrolizumab. Such patients would usually belong to the IMDC favorable risk category at the time of recurrence and could have a continued disease free interval post metastasectomy based on sever...
What is your preferred approach to low volume unresectable/metastatic favorable risk RCC?
For good-risk metastatic RCC patients, who are considered not a candidate for cytoreductive nephrectomy, systemic therapy with one of the IO/TKI combinations is indicated, taking into consideration the patient’s comorbidity and tolerance to the regimen. (For non-clear cell metastatic RCCs, systemic ...
How do you approach a patient with undifferentiated pleomorphic sarcoma encasing the spinal cord post radiation for neurological deficits for further management?
We will need some more information here. Did the patient present with cord compression? What level of cord is involved? Is the tumor causing functional issues in the patient (paralysis, bladder issues, etc.)? What was the dose of radiation used? Was this definitive RT or palliative RT? Is there any ...
Is narrow-band ultraviolet B (nbUVB) phototherapy contraindicated or recommended with caution in patients with a personal history of melanoma?
Although it is challenging to be definitive, our current literature suggests that nbUVB does not increase the risk of melanoma or nonmelanoma skin cancer.Previous studies suggesting a possible increased risk with nbUVB included patients with a history of PUVA, which has been shown to increase risk. ...