Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you manage a patient with sickle cell disease who is infected with COVID-19?
We have limited knowledge about this management. The Sickle Cell Disease Association of America's Medical and Research Advisory Committee has issued a provider advisory. Also, Dr. Julie Paniepento has created a registry that can be viewed in real time here: https://covidsicklecell.org/ In general, t...
How would you treat a patient with biopsy-proven recurrent urothelial bladder cancer with M1a disease (limited to retroperitoneal nodal disease)?
Systemic therapy with either clinical trial, or chemotherapy (ideally cisplatin-based or carboplatin/gemcitabine if cisplatin-unfit), or immune checkpoint inhibitor (if it is first line treatment setting and cisplatin-unfit, options include either pembrolizumab or atezolizumab, if either 'PD-L1 high...
How would you manage a patient with primary CNS lymphoma who received R-MTX followed by autologous transplant with systemic relapse 5 years later for which R-Pola-CHP was given now followed by CNS relapse?
Dr. @Dr. First Last - certainly an interesting and unusual scenario! I'm presuming that the patient is fit for intensive approaches. This is a patient whom I would consider for CAR-T as a treatment of multiply relapsed DLBCL. Depending on the symptomatic and anatomic burden of the CNS disease, debul...
In a patient with HR+HER2+ early breast cancer who is receiving adjuvant T-DM1 for residual disease, do you overlap endocrine therapy with T-DM1?
Yes, in the KATHERINE trial, endocrine therapy was started concurrent with the T-DM1, same with radiation as indicated. This is included I believe in the published supplement in KATHERINE. So...yes, both endocrine therapy and radiation are fine to start while on T-DM1.
In patients with early-stage follicular lymphoma undergoing definitive RT, do you approach grade 3a disease any differently than grade 1-2 (radiation dose, fields/margins, systemic therapy)?
Our philosophy is based on whether it is grade 3A or 3B. If it is 3A, then we treat like low grade lymphoma with RT (similar dose and principle) but if it is 3B, then treat with chemotherapy +/_ RT like diffuse large B cell lymphoma.
Is there evidence to support or argue against intermittent fasting for cancer patients?
This is a complex topic with many permutations of dietary interventions similar to fasting such as calorie restriction and “fasting mimicking”, but as it pertains to pure fasting, I know of a few small studies which characterize fasting around the time of chemotherapy infusions (Raffaghello et al., ...
How would you treat a primary angiosarcoma arising in the skull, excised with initial excisional biopsy?
I would try to get some more information first. Is this a cutaneous primary invading into skull, or a lesion arising primarily in the skull? Is there any evidence of violation (tumor or iatrogenic) through calvarium such that dura is threatened? I would stage with a careful skin exam for any cutaneo...
How does metaplastic thymoma histology impact your decision regarding adjuvant radiation?
This is a good question. I honestly have never seen this histology, and I help write the UpToDate thymoma section and am a thymoma enthusiast (meaning I like to read about it/treat it, not to have it). Thymomas really run the spectrum of aggressiveness, and the approach to them in the adjuvant setti...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...
Would you give immunotherapy after neoadjuvant gem-cis for bladder cancer if cystectomy is being postponed for months due to non-autoimmune/unrelated comorbidities?
Delay in cystectomy regardless of the use of neoadjuvant chemotherapy is associated with compromised survival outcomes (Chu et al., PMID 30840335) and if a patient receives neoadjuvant chemotherapy and is unable to undergo cystectomy for months due to comorbidities, there is no clear data to support...