Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How quickly do you expect iron stores to decrease after starting iron chelators?
This is a complex answer to what seems like a simple question. It is not a standard rate of decline because each patient's situation is different. It is always about the balance of how much iron is going in vs. how much iron is being excreted. Essentially there are 4 variables that must be considere...
How do you approach rising PSA many years after prostatectomy with negative PSMA PET?
The devil is in the details. What is the status of the patient? In other words, what is the expected survival of the patient given his age, performance status, and medical conditions? There are online calculators that can be used to help. At what PSA value was the PSMA scan obtained? The utility of ...
Given the current COVID-19 pandemic, how long would you delay mastectomy post neoadjuvant chemotherapy?
Consideration should be given to perform surgery for post neoadjuvant patients no later than 8 weeks. No difference for subtypes. Sanford RA et al reviewed the MD Anderson breast cancer database for stage 1-3 patients undergoing neoadjuvant chemotherapy between 1995-2007: a sensitivity analysis comp...
How would you manage a borderline resectable pancreatic cancer s/p induction chemo + chemo-RT who was unable to go to surgery?
Tough situation. If there was stable/slight progression of disease at 6 months, I would not be inclined to offer reirradiation at that time. If any possibility of radiographic stability, tumor markers were stable, and the patient was clinically well, I would continue with close surveillance. If clea...
How would you approach secondary stroke prevention in an adult with Hemoglobin SC disease?
Stroke is less common in HbSC disease than it is in HbS homozygotes (Ohene-Frempong et al., PMID 9414296). Thus, there are no studies focused on primary or secondary stroke prevention in HbSC disease. Recent guidelines for stroke management were “silent” on stroke in HbSC disease (DeBaun et al., PMI...
How do you decide between systemic antiangiogenic therapies for HHT?
Pomalidomide was just recently published in NEJM (Al-Samkari et al., PMID 39292928) showing efficacy in improving epistaxis in patients with HHT. It has an advantage as it is an oral agent versus bevacizumab being an IV infusion. Bevacizumab, however, has previously shown efficacy in smaller studies...
In what situations would you consider ESAs in hospitalized patients with severe anemia for indications other than CKD or myelosuppressive chemotherapy (e.g., ACD, hemorrhage)?
In deciding on the risk-benefit of ESAs in patients with severe anemia due to bleeding and/or inflammatory disease, there are two considerations. The first is the severity of the anemia and consequently, the time to initial response. Using the standard dose of ESAs, it may take 8 to 12 weeks to achi...
Is there a role for pre-operative RT (+/-chemo) for a borderline resectable Klatskin tumor as an attempt to try to get them to surgery?
From my perspective, there is a role for preoperative chemo-radiation for borderline resectable Klatskin tumors followed by re-evaluation for surgical resection (standard resection vs liver transplant). Neo-adjuvant chemo-radiation followed by liver transplant has been evaluated as a treatment opti...
What palliative, systemic treatment would you consider for a patient with an extensive Klatskin tumor with associated hyperbilirubinemia (bilirubin >20) not amenable to local intervention?
Localized Klatskin (hilar) cholangiocarcinomas defined as disease without nodal or metastatic spread and less than 3cm in size radially above the cystic duct are potential transplant candidates with the Mayo Clinic Protocol (Zamora-Valdes and Heimbach. PMID 29735023).For disease not meeting the abov...
How do you approach IVIG replacement for pediatric patients with low IgG during treatment for hematologic malignancies?
We monitor IgG levels at the beginning of each chemotherapy cycle for infants, for patients with Down syndrome, for those receiving blinatumomab, and for patients who are hypogammaglobulinemic with recurrent bacterial infections, and we replace when IgG levels are <400 mg/DL for down syndrome and <5...