Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
Would you prescribe TKIs for Stage IV differentiated thyroid cancer patients who are RAI-naive, with preserved performance status, and are not eligible for surgery?
TKI therapies, including those targeting RET, NTRK, and BRAF are indicated for patients with RAI-refractory disease. I am assuming the patient in question has locally advanced disease that requires surgery, but is too advanced for resection. Presently, we do not have data to support the use of TKI t...
Is there any indication for hydroxyurea in patients with sickle cell trait?
No. Of course, be sure it is the correct diagnosis and not HgA + HgS (beta+) which, as you know, shows HgA and HgS on electrophoresis and can/will be called trait if not looked at by someone experienced to note if A> S or if S > A. If MCV is low. If HgA2 is up. HgF up etc... If indirect Bili/LDH/AST...
Would you start anticoagulation in a patient with provoked blood clot in the past now with labs done for rheumatological reasons showing triple positive APLA?
The short answer is that I would probably not anticoagulate this patient as a history of prior thrombosis is hard to connect to the currently positive APL antibodies. I would certainly obtain a second set for future risk stratification. However, there are several variables that could influence the ...
How would you approach treatment for a glioblastoma from a radiation standpoint that was initially thought to be a metastases and therefore treated with multiple courses of SRS over the past few years?
It appears that the patient was empirically treated with multiple SRS courses; then, presumably, the patient must have undergone a biopsy/resection which disclosed the true nature of the problem (GBM). Therefore, the question is, what is the appropriate postop treatment for this patient? There are s...
How would you treat rapidly growing inflammatory breast cancer, invasive lobular triple negative subtype, after two cycles of neoadjuvant KEYNOTE 522?
This is probably the single most difficult subtype of breast cancer to treat as it tends to be horribly chemo insensitive and molecularly most are actually luminal B and not basal. If growing on the carbon/Taxol/pembro portion of KEYNOTE, I would switch immediately to AC/pembro with a low threshold ...
What is the best second line treatment for a HER2+ metastatic breast cancer treated with frontline paclitaxel and anti-HER2 therapy?
I would use T-DM1 (ado trastuzumab emtansine) in this situation as a second line therapy. T-DM1 has a very favorable side effect profile. Pertuzumab added a survival benefit when combined docetaxel and trastuzumab (median of 15.7 months) though this was a first-line treatment (Swain et al. NEJM 2015...
Would you offer neoadjuvant chemotherapy to high grade T1 urothelial carcinoma in a bladder diverticulum?
Due to anatomical considerations (lack of muscularis propria in the diverticulum wall), clinical staging is very challenging in this setting. That is a great example of how a multi-disciplinary clinic of experts, including Urologists, Med Onc, Rad Onc, Radiologists, and Pathologists, can help get a ...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
For patients with well differentiated NET whose carcinoid symptoms are controlled on SSAs but have persistently elevated 5HIAA, would you consider adding telotristat for prevention of carcinoid heart disease?
I do not think routinely adding therapies to treat biochemical parameters is appropriate.As many are likely aware, the tryptophan hydroxylase inhibitor telotristat was approved for the treatment of carcinoid syndrome diarrhea based on the TELESTAR study, which demonstrated a statistically significan...
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...