Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
In patients with iron deficiency due to history of gastric bypass or IBD, would you consider oral iron therapy if the iron deficiency anemia is mild?
Oral iron can often be effective in iron deficiency, as long as absorption is intact. If you are concerned about absorption, performing an oral iron challenge can be useful in allowing you to avoid long trials of oral iron that will be ineffective. Simply check an iron panel at baseline, then admini...
When would you offer single fraction adjuvant partial breast irradiation instead of a 5-10 fraction course for early stage breast cancer?
We have not offered a single fraction, and our standard is 26 to 30 in 5 fractions. Data on a single fraction is not enough to support this recommendation for now.
Would you give a PARP inhibitor, and at what dose, to a patient with end-stage renal disease on hemodialysis after completion of 6 cycles of carboplatin and paclitaxel for advanced ovarian cancer?
This is an interesting question, for which I don't have a quick answer.When it comes to PARP inhibitors (PARPi), there is compelling data for its use as maintenance therapy as well as recurrent treatment. The article by Kurnit et al., is a nice summary of the data available supporting PARPi use (Kur...
What would be the next step if a patient’s serum testosterone remains above 40 several weeks after the initial dose of a GnRH agent in the treatment of prostate cancer?
Real-world data show that approximately 3-7% of patients experience breakthroughs above 40 ng/dL per patient course, while 6.6% experience breakthroughs above 32 ng/mL (1.1 nmol/L). When using the lower threshold of 20 ng/dL (0.7 nmol/L), breakthrough rates increase to approximately 41%. One large r...
Would you consider use of PARP inhibitors in patients with metastatic breast cancer with moderate penetrance germline mutations such as CHEK2, ATM, RAD51?
In the Olaparib Expanded (TBCRC 048) study published by @Dr. First Last in JCO, there were no responses to olaparib in metastatic breast cancer with germline or somatic CHEK2 or ATM pathogenic variants (mutations). In contrast, responses were seen in metastatic breast cancer with PALB2 pathogenic va...
How do you counsel patients on the efficacy of breast cancer risk reduction strategies such as breast MRI surveillance or bilateral mastectomy for those considered high risk by polygenic risk score, pathogenic variants, and/or family history?
This is a difficult question with limited data to guide decisions. The ultimate goal of any screening effort is to identify disease earlier so that treatment is more effective (and hopefully less onerous) so that fewer patients die. We have good data that enhanced screening in high risk populations,...
Would you hold immunotherapy if a patient with metastatic melanoma has stable disease for 6 months?
We would usually not stop therapy in a patient with a stable disease as best response after only 6 months. In Keynote 006, patients had to stop therapy after 2 years of treatment. In this trial, 12 patients were in stable disease after 2 years. Ten of them were still in stable disease after 9 months...
How would you approach a patient with vitreoretinal lymphoma without CNS or systemic involvement?
The optimal treatment approach for primary intraocular lymphoma is debated. This is a rare disease with only small retrospective series guiding therapy. There is no clear superior treatment approach in the literature. In clinical practice, younger patients are often treated initially with high-dose ...
How would you integrate immunotherapy into the treatment of a patient with recurrent, widely metastatic gastric adenocarcinoma after initial treatment with perioperative EOX and subtotal gastrectomy?
I agree with my friend, @Dr. First Last. Firstly, I hope that this is an entirely theoretical scenario or that the patient received EOX many years ago, prior to the FLOT4 data that established FLOT as the current standard-of-care. As Dan also mentioned, for patients who cannot tolerate FLOT, FOLFOX ...
How would you treat AML in a pregnant patient at 12 weeks' gestation?
My answer is under the assumption that, after a multi-disciplinary discussion with the patient, oncology/leukemia team, and maternal fetal medicine, the objective is to initiate AML-directed therapy while maintaining the pregnancy. The highest risk of deleterious impact to the fetus from chemotherap...