Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Should platelet transfusions be considered for anti-platelet agent reversal in patients with major bleeding?
Patients on plavix and/or aspirin are at risk for bleeding whether in relation to surgery or bleeding from the gi tract. Much like the management of patients on anticoagulation temporary reversal of antiplatelet drugs is only achieved by normalizing platelet function. This is the same principle used...
With the intent for cure, what neoadjuvant therapy would you give a patient with only chest wall recurrence 10 years after an advanced breast cancer was managed with mastectomy, ddAC and T, and 5 years of adjuvant endocrine therapy?
A chest wall recurrence is associated with high risk of metastatic disease either at time of diagnosis of the chest wall recurrence or over the next 5 years. Women who develop chest wall recurrences should be restaged. The approach to an isolated chest wall recurrence in this case is surgery with cl...
How do you counsel patients with locally advanced malignancies who have ECOG 3-4?
I agree with @Dr. First Last and @Dr. First Last's comments about the implications of PS and specific situations where medical therapies have the potential to improve PS (heme malignancies small cell) and/or extend quality of life. I have two goals in this conversation. To make sure I understand the...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
How do you manage concurrent non-life-threatening hemoptysis and acute pulmonary embolism?
Hemoptysis can occur with PE when there is pulmonary infarction. However, the majority of pulm embolism cases have pleuritic chest pain without infarction. Significant hemoptysis is very rare in these cases and anticoagulation is nearly always safe. When hemoptysis continues or the volume is concern...
What is your strategy for breakthrough chemotherapy induced N&V in patients receiving highly emetogenic chemotherapy and already received a NK-1 antagonist, 5-HT3 antagonist, dexamethasone, and olanzapine?
I find the MASCC anti-emetic guidelines to be very well written Davis et al., PMID 34398289.Very few randomized clinical trials in cancer for antiemetics (with positive trials associated with metoclopramide (D2 receptor antagonist) and olanzapine).So - most are based on trial and error + clinician p...
What is your protocol for transitioning to oral anticoagulation post-thrombolysis for pulmonary embolism?
My answer has multiple parts."Thrombolysis" is not all the same. As studied in stroke treatment, alteplase causes marked fibrinogen depletion and coagulopathy (prolonged PT, aPTT), whereas tenecteplase doesn't so much (Huang et al., PMID 26514192).So, if alteplase was used (systemic or reduced cathe...
Do you routinely check Pulmonary function testing prior to each cycle of BEP for young patients with testicular cancer with no pulmonary risk factors?
A few comments: I do not check DLCO or PFTs in general in patients under age 50 getting just 3 courses of BEP. We tend to avoid bleo if over age 50. If a patient is getting 12 weeks of bleo, I check DLCO just prior to the start of the 4th course, and if DLCO < 60%, I give VIP for the 4th course. Ad...
Do you always biopsy suspicious liver lesions if you have a biopsy from the pancreatic mass showing PDAC?
I don’t always biopsy especially if the tumor marker is very high. I start with treatment and reassess. I do think a good liver MRI with contrast can be helpful here as well. One important caveat: I do biopsy if there is scant tissue from the pancreas biopsy so I can send the NGS panel.
Is there ever a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?
Excellent question. There is certainly a need! If we step back and take an honest look at our control rates with SBRT, while primary tumor control rates are high, we suffer the same viciousness of lung cancer that surgeons do - local control is trumped by a 2-3x rate of regional and distant failure....