Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Is there a rationale for treating medically inoperable stage I-III breast cancer patients with RT alone?
We treated stage III patients with "radical radiotherapy" with or without chemotherapy when I was a resident in the early 1980s, since they were considered SURGICALLY inoperable then. However, very high doses were needed (75-80 Gy to the primary using external beam followed by interstitial implants)...
How do you dose apixaban in patients with CrCl <30 mL/minute?
Patients with chronic kidney disease are challenging to treat with anticoagulation as they have an increased risk of both venous thromboembolism and bleeding. Treatment should be individualized after weighing the risks and benefits of anticoagulation as well as the indication for anticoagulation. Th...
What is the role of consolidative durvalumab and prophylactic cranial irradiation in patients with stage I small cell lung cancer?
In the ADRIATIC study, stage I or II limited-stage SCLC comprised only about 12% of patients randomized. The point estimate of HR regarding survival benefit was 0.92, with a wide confidence interval exceeding 1.0 (upper range more than 2). I do not recommend durvalumab consolidation for those with s...
How do you manage a patient with JAK2+ ET without history of thrombosis during pregnancy?
Great question. We've recently published our experience here How et al., PMID 33022566. Patients with ET that are pregnant and that don't have a history of thrombosis are likely to be in the very low/low risk categories by R-IPSET, many of these women are likely not on any treatment prior to startin...
What radiation treatment volume and dose would you deliver to an isolated DLBCL relapse in the left eye s/p vitrectomy and intraocular methotrexate?
This is a case of secondary ocular lymphoma but the management of primary ocular lymphoma may be helpful to consider. For patients with primary ocular lymphoma, a significant number of patients present with bilateral disease at initial diagnosis or will relapse in the contralateral eye after unilate...
Aside from adrenal insufficiency and thyroid toxicities, how do you approach other hormonal imbalances during treatment with immune checkpoint inhibitors?
A systematic review (Barroso-Sousa et al., PMID 28973656) indicated that hypophysitis can occur in 3.2% of patients treated with ipilimumab (Yervoy) and this increased to 6.4% when combined with nivolumab (Opdivo). Obviously, adrenal and thyroid functions need to be assessed first but other function...
What is the appropriate approach to manage a patient with triple-negative, locally advanced breast cancer (LN+) who progresses on neoadjuvant chemo-immunotherapy (KEYNOTE-522 regimen)?
Given the aggressiveness of the KEYNOTE-522 regimen, second-line chemo seems unlikely to be effective. Assuming the patient is currently not resectable, recommend breast RT concurrently with a well-tolerated radiosensitizer, e.g., capecitabine, dose, and fractionation depending on the presence or ab...
Is prophylactic anticoagulation indicated in patients with frequent ulcerative colitis flares?
Background: We know that inflammatory bowel disease (IBD) is a risk for incident and recurrent venous thromboembolism (VTE). What is not clearly established is whether the IBD needs to be 'active' in order for it to be a risk factor, e.g. would patients who have had proctocolectomy (and perhaps no e...
When would you continue bevacizumab versus using PARPi alone for maintenance therapy in BRCA+ or HRD+ ovarian cancer after response to primary platinum + bevacizumab?
In patients who start treatment with combination platinum based chemotherapy + bevacizumab, and are found to be BRCA+ or HRD+, I will commonly continue bevacizumab and layer on the PARPi in the maintenance setting. This is based on both the PAOLA-1 data, as well as the population adjusted indirect c...
Would you change an elderly, frail patient with atrial fibrillation who is already on a NOAC to VKA treatment?
I wouldn't on the basis of this study. Aside from the other limitations of the FRAIL-AF trial, this study only addressed the utility of switching a stable patient from VKA to NOAC and not vice versa. A patient who is doing well on an appropriately dosed NOAC may experience difficulty achieving adequ...