Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How would you approach adjuvant treatment in a patient with completely resected undifferentiated pleomorphic sarcoma of the chest wall that recurred after 2 years, initially treated with neoadjuvant radiation and resection?
There is no evidence to support adjuvant treatment after re-resection. In the case of recurrence, we prefer to biopsy the mass to prove recurrence and obtain tissue (for NGS). In the case of recurrence, if we were to give systemic therapy, then we would favor neoadjuvant chemotherapy- provided this ...
Do you have a higher threshold regarding when to hold bevacizumab for proteinuria in patients who had known baseline proteinuria from diabetic nephropathy?
This is an interesting question. It’s not uncommon to have patients with cancer who have other underlying conditions that may lead to proteinuria. I don’t have a higher or lower threshold to recommend holding VEGF inhibitors, but in all patients who are on them who develop proteinuria, the degree of...
Can radiation therapy alone for localized recurrence of high-grade B-cell lymphoma be considered for those that previously received rituximab-based chemotherapy?
High-grade B-cell lymphomas are distinct entities no longer classified as "diffuse large B-cell lymphoma" by the WHO. They include: High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements (often referred to as double hit or triple hit lymphoma). High-grade B-cell lymphoma, NOS (thes...
How do you respond to a patient who asks "Why do I still need breast radiation after chemotherapy if chemotherapy treats the whole body?"
Perhaps one of the best arguments supporting RT in breast cancer is the not-that-often cited Scottish Trial that randomized women to postoperative RT or chemotherapy following breast conservation; the breast failure rate following adjuvant chemotherapy alone approximated 30% with short follow-up. Ob...
How would you treat an elderly patient with biopsy proven extensive non-resectable metastatic pseudopapillary pancreatic tumor?
This response is for cases that curative surgery or debulking surgery is not an option. These patients may respond to targeted therapy or hormonal therapy. We perform genomic profiling. If alterations are present which lead to the activation of PI3K/AKT/mTOR pathway, we use everolimus or temsirolimu...
Will you offer olaparib + abiraterone for all patients with metastatic castrate resistant prostate cancer based on results of PROPEL trial?
PROpel is clearly positive for its primary endpoint of delaying rPFS significantly in ALL first line mCRPC patients above and beyond abiraterone and prednisone alone. The delay of 8-10 months over an active comparator is significant both statistically and clinically, and is similar to the improvemen...
What is your goal ferritin level in pregnancy?
The goal is really to avoid iron deficiency and <30 best defines this state. Need to be wary of circumstances such as inflammation where the ferritin level may be falsely high even in the setting of reduced body iron.
When is the ideal time to start adjuvant nivolumab after radical surgery in urothelial carcinoma?
In the reported and ongoing adjuvant therapy trials, patients must have had radical surgery (R0, with negative surgical margins) within 120 days before randomization. However, it is biologically rational to target initiating therapy as soon as he/she is fit for nivolumab following surgery (data in t...
Can TPO agonists, like avatrombopag or lusutrombopag, be used for patients with chronic thrombocytopenia and new acute portal vein thrombosis?
A caveat before answering - these tend to be very difficult clinical situations in a population that often has cirrhosis and has a very difficult-to-predict hemostatic picture (whether they are prohemorrhagic or prothrombotic from the underlying liver disease).I would refer you to some of the excell...
How do you approach adjuvant therapy for patients with advanced ovarian cancer who undergo interval debulking surgery following six cycles of neoadjuvant chemotherapy?
If viable tumor at the time of surgery and patient has acceptable performance status then I would treat 2-3 more cycles of chemo followed by maintenance therapy. However, if no viable tumor at the time of surgery then I would forego IV chemotherapy and start maintenance postoperatively depending on ...