Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
What are the treatment options for patients with duodenal cancer who have progressed on FOLFIRINOX?
The quality of evidence for almost all treatments in small bowel adenocarcinomas is poor to some extent. First, I would look at the NGS data I am sure you have or can obtain easily for a molecular treatment if applicable (TMB > 10 = pembrolizumab, MSI-H = checkpoint inhibitor, NTRK = e.g. entrectini...
What systemic therapy would you offer a patient with metastatic melanoma who is BRAF WT and developed metastases while on adjuvant nivolumab?
Adding an anti-CTLA4 agent after progression on anti-PD1 (even in the adjuvant setting) should be a reasonable choice for patients who are ineligible for clinical trials. In our practice, we recommend using the CheckMate 067 dose (Ipi 3 and Nivo 1) when faced with such a situation. Zimmer et al., PM...
In what situations do you utilize G-CSF in germ cell tumors or Hodgkin lymphoma patients receiving bleomycin?
Having been both a lymphoma doctor and germ cell tumor doctor, I can tell you our experience. The current standard for poor risk germ cell tumors is to routinely include G-CSF with BEP X 4 and VIP X 4 in most high volume centers. A number of experts include growth factors routinely in good risk pati...
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
How do you approach very treatment-refractory ITP?
Severely refractory ITP doesn't account for a large fraction of ITP patients, but it can be quite a challenge for treaters and patients alike. Combination therapies, varied immunosuppressive agents, and careful checks on adherence are all helpful. Some alternative agents with entirely different mech...
How do you approach very treatment-refractory ITP?
Severely refractory ITP doesn't account for a large fraction of ITP patients, but it can be quite a challenge for treaters and patients alike. Combination therapies, varied immunosuppressive agents, and careful checks on adherence are all helpful. Some alternative agents with entirely different mech...
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...
For a patient with T3N1M0 esophageal adenocarcinoma, who suffered esophageal perforation necessitating metallic stent placement, would you favor a neoadjuvant chemoradiation or perioperative chemotherapy approach?
In situations of esophageal perforation, the main concern will be the dissemination of disease particularly in the thoracic cavity, i.e. pleura. Therefore, I favor a systemic therapy approach upfront. Should the patient have a good response to systemic therapy, then chemoradiation could be considere...
Does your approach to first line treatment of metastatic colon cancer change for a mucinous adenocarcinoma?
Thanks for the question! I think at this time, molecular features of cancer are more likely to impact treatment choices over histology! For example, we have several biomarker-driven options including MMR-D (KEYNOTE 177, CheckMate 8HW) BRAF (BREAKWATER) and we will likely see similar practice-changin...
Is there a role of definitive radiation or prostatectomy, in a patient who has M0 castrate resistant prostate cancer and whose PSA is undetectable on ADT and enzulatamide?
The question posed comes from a rather unusual clinical situation. In most cases, M0 crpc would have evolved from a diagnosis of prostate cancer and the application of curative intent local therapy surgery/radiotherapy, with psa progression in the absence of metastatic disease managed with ADT now w...