Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
For newly diagnosed ALK or EGFR + NSCLC with oligometastases to brain only and otherwise cN0-1 thoracic disease, would you offer targeted therapy alone or SRS to brain + concurrent chemoradiation/surgery to chest?
For asymptomatic patients with smaller lesions, I would offer initial osimerinib or alectinib and get MRI with SRS planning sequences at 1month. We would then SRS any non-responding lesions
When would you initiate chronic therapeutic phlebotomy in a patient with erythrocytosis secondary to a high hemoglobin-oxygen affinity hemoglobinopathy?
The large majority of patients with high oxygen affinity hemoglobinopathy do not require therapeutic phlebotomy. There is a subset of patients who develop symptoms (generally these are non-specific such as headache) or complications such as thrombosis. There seems to be no correlation between hemato...
Do you recommend lifelong antibiotic prophylaxis, or do you prefer a more selective approach based on risk factors in asplenic patients without a history of severe infections?
The advice is limited by the fact that there are no randomized controlled trials in adults on daily antibiotic prophylaxis post-splenectomy. There are trials in children with sickle-cell disease that do show a benefit, but it is not clear that these can be extrapolated to splenectomized adults. Furt...
Would you consider elective neck nodal irradiation for a large >5 cm head and neck extramedullary solitary plasmacytoma arising from the nasal cavity?
A plasmocytoma in the nasal cavity may bear a higher risk for nodal involvement if it involves Waldeyer's ring or nasopharynx.Adding ENI to the neck will certainly increase the risk of toxicity and only lead to a modest benefit in terms of isolated regional recurrence. I would thus not perform elect...
Should post-transplant cyclophosphamide be utilized for all matched unrelated donor peripheral blood stem cell transplants for hematologic malignancy?
In myeloablative transplantation, PTCY did not have an advantage over Tac/MTX as demonstrated in the BMT-CTN 1301 study which compared PTCY, Tac/MTX, and T cell depletion (Luznik et al., PMID 34855460). One caveat is that in this trial, PTCY based prophylaxis did not include Tac or Tac/MMF.BMT-CTN 1...
Should post-transplant cyclophosphamide be utilized for all matched unrelated donor peripheral blood stem cell transplants for hematologic malignancy?
In myeloablative transplantation, PTCY did not have an advantage over Tac/MTX as demonstrated in the BMT-CTN 1301 study which compared PTCY, Tac/MTX, and T cell depletion (Luznik et al., PMID 34855460). One caveat is that in this trial, PTCY based prophylaxis did not include Tac or Tac/MMF.BMT-CTN 1...
Do you hold palbociclib (or another CDK4/6 inhibitor) in a patient with metastatic HR+ breast cancer while receiving palliative radiation?
Currently there are no large studies on combining radiation therapy with palbociclib. Many of the patients with hormone receptor positive metastatic breast cancer have bony metastases and often need radiation for palliation. There is a small study showing that combination of radiation and palbocicli...
In a patient with cryptogenic stroke while on antecedent aspirin 81 mg, how do you decide between single antiplatelet therapy, dual antiplatelet therapy, or antiplatelet agent combined with anticoagulation such as rivaroxaban 2.5 mg BID?
This question assumes that a thorough workup has been completed, and the patient does not have paroxysmal a fib, a PFO, an intracranial stenosis, a hypercoagulable state, or vasculitis. This workup is the most important issue. If all is negative, and the stroke is relatively minor (NIHSS less than o...
Would you consider adding abiraterone or docetaxel in patients with high risk prostate cancer whose PSA does not become undetectable after ADT and radiotherapy with castrate level testosterone?
There are three concepts here at its core: Does adding abi or doce to ADT/RT in high-risk PCa improve outcomes in unselected patients? Does a detectable PSA while on ADT impact prognosis? Does intensifying therapy in patients with a detectable PSA while on ADT improve outcomes in this subset? Here a...
How do you approach patients with severe mucositis receiving chemo-radiation for head and neck cancer with regards to empiric antifungal or antiviral treatment?
Severe mucositis remains a problem for patients receiving chemoradiotherapy for locally advanced head and neck cancers. While neutropenia can occur in some patients, it is not as frequently seen when compared to those who undergo bone marrow transplants, meaning that our patients do not commonly dev...