Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For T1b or T2a NSCLC cancer, approached with SABR, should chemotherapy be considered in the adjuvant setting?
It is not standard of care to give adjuvant chemotherapy in IA NSCLC.It can be considered in certain situations of stage IB, although there is no strong prospective data. The group with > 4 cm size tumars had some benefit in an unplanned subgroup analysis of the CALGB study. If other risk factors be...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
Would you recommend radiotherapy to upper-tract urothelial carcinoma in an inoperable patient?
Unfortunately, there are no good data to guide a decision in this circumstance. Assuming that this is a patient with a small tumor localized to the upper tract with no evidence of nodal or distant disease, radiotherapy might be a reasonable option to either palliate symptoms due to obstruction or bl...
Would you consider starting immunotherapy in a patient with stage IV NSCLC, a high PDL1 level, and active, untreated hepatitis C?
The short answer is yes, while also sending the patient to hepatology for HCV treatment. If the patient has minimal disease burden and systemic therapy can be delayed, one small study in patients with NSCLC showed that starting ICI about 14 days after HCV treatment appeared safe. Although patients w...
How do you approach cisplatin ineligible patients with bulky EBER positive nasopharyngeal SCC for induction chemotherapy?
For patients who are cisplatin-ineligible, I substitute with carboplatin. There have been studies such as the one below which show that the regimen of carboplatin and gemcitabine is effective and well-tolerated. Lim et al., PMID 23369852 Conclusion: The use of induction carboplatin and gemcitabine f...
Has use of PSMA PETCT revealed increased local failures than previously known after definitive prostate EBRT with biochemical failure?
Prior to the advent of PET imaging, the published rates of local recurrence (LR) after definitive RT vary widely in phase III trials from ≈ 1% (e.g., PCS IV) to ≈ 30% (e.g., PROG 9509). The heterogeneity is likely explained by several factors including (1) differences in baseline risk of local recur...
How would you manage a cT4N0 HER2- distal esophageal adenocarcinoma, CPS score 30, with good response to neoadjuvant chemo-RT on PET and residual disease on EGD in a patient who declines surgery?
There's really no good answer here. What one does is predicated largely on how much faith one has in the efficacy of nivolumab.The benefit of adjuvant nivolumab in patients with locally advanced esophageal cancer who underwent trimodality therapy and had residual disease is of course based on the Ch...
Can PRRT be used in a patient with a GI neuroendocrine tumor and estimated GFR of less than 30?
Unfortunately there is no safety data for the use of PRRT in patients with GFR <30 ml/min. A creatinine clearance <50 ml/min is listed only as a relative contraindication by NANETS/SNMI (Hope et al 2020) and ENETS guidelines (Hicks et al 2017). Based on over 2 decades of experience with PRRT, the lo...
What infectious prophylaxis do you use for patients with newly diagnosed multiple myeloma?
Excellent question for sure. In order of controversial nature/lack of evidence/lack of consensus around evidence: 1) Antiviral prophylaxis - I don't think there's any controversy around this, particularly in patients on PIs and/or a CD38 mAb. We do use acyclovir even in patients who have received th...
In what situations, if any, would you recommend NALIRIFOX over FOLFIRINOX for first-line treatment of patients with unresectable pancreatic cancer?
Given the currently available information, I would not use NALIRIFOX instead of mFOLFIRINOX in any situation.My reasons for this are: mFOLFIRINOX has been the standard of care for the treatment of metastatic and unresectable pancreatic cancer in patients who can tolerate this regimen for over a deca...