Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you approach management for CCUS with severe cytopenias?
This is a very timely question since CCUS is now much better defined. CCUS (Clonal cytopenia of undetermined significance) is not a new syndrome, it is a subset of myelodysplasia (MDS), both of which as late as 1983, were actually known as: "Preleukemia". CCUS is an uncommon form of MDS, which has v...
What would you recommend for pTa, stage 0a papillary urothelial carcinoma of the distal ureter?
I think a lot would rest on the grade (and presumably upper tract imaging was otherwise negative) – if low grade could do endoscopic resection and monitor, if high grade could consider neoadjuvant therapy with ureterectomy vs nephroureterectomy. …also depending on age, comorbities, etc.
What is your approach to patients with severe infusion reaction but excellent response to checkpoint inhibitors?
In patients with very severe infusions reactions, ie anaphylaxis, I would discontinue the checkpoint inhibitor, as it is very likely that the response will persist after discontinuation of the therapy. This is the type of patient that I would favor a treatment holiday with close interval surveillanc...
How do you counsel a woman with a BRCA1 VUS with a high-risk personal history of breast cancer?
There is real harm to patients by ‘acting’ on the presence of VUS in BRCA1; the majority are reclassified as benign. For those who have access to genetics resources, it is very helpful to discuss these results with certified genetics counselors, and formal post-test counseling for patients is recomm...
How will the PROSPECT trial presented at ASCO 2023 change your current management of early rectal cancer?
I can’t overstate how much credit the Principal Investigator, Dr. @Dr. First Last, deserves for successfully completing the PROSPECT trial. The oncology community, particularly the radiation oncology community, was concerned that omitting radiation would put patients at risk. It was difficult and ch...
How long post operatively do you wait before transitioning from parenteral anticoagulation to oral anticoagulants after pulmonary thromboendarterectomy for CTEPH?
It depends. In straightforward cases, we are pretty aggressive with starting anticoagulation to prevent re-thrombosis after pulmonary thromboendarterectomy. These patients are started on parenteral anticoagulation (with IV heparin) on POD #0, usually within several hours after arriving in the ICU if...
What is the preferred approach to managing non-occlusive or partially occlusive venous sinus thrombosis?
I would recommend a DOAC, particularly apixaban, with follow-up imaging in 3 months.
How do you manage immunotherapy-induced myasthenia gravis?
My go-to algorithm is well-represented in the paper by Dr. @Dr. First Last et al. Zubair et al., PMID 36439604
Do you give trastuzumab to women with small, lymph node negative, HER2-positive breast cancer?
Size, hormone receptor status, age, cardiac risk factors and patient opinion matter.HER2 itself is only a moderately strong poor prognostic factor; histologic grade, size, and nodal status carry greater prognostic information. Most T1, N0, HER+ breast cancers, particularly ER+, cancers, had an excel...
How do you manage a patient with low risk MDS who achieves transfusion independence with luspatercept but continues to have fatigue?
This is a challenging question and I'm not sure there's clear data to support a practice one way or another. Anecdotally, I have noticed that when using Luspatercept, it seems to improve hemoglobin reliably and therefore lead to less transfusions, but I have not observed a consistent concordant impr...